MEDICARE: DR. JACQUELINE B BENNETT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1316900889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE B BENNETT PH.D.

Provider Business Mailing Address
First Line	:	213 CAMINO REAL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-8907
Country	:	US
Telephone Number	:	970-493-6667
Fax Number	:	970-493-8016

Provider Business Practice Location Address
First Line	:	1945 ROBERTSON ST.
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524
Country	:	US
Telephone Number	:	970-493-6667
Fax Number	:	970-493-8016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/08/2007

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