MEDICARE: AMANDA JO BENNETT PRSS

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	175T00000X	Peer Specialist	25-9150SUD	WV
2	172V00000X	Community Health Worker		WV

General Provider Information

NPI Number	:	1558234005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JO BENNETT PRSS

Provider Business Mailing Address
First Line	:	1236 5TH AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-2207
Country	:	US
Telephone Number	:	681-229-4531
Fax Number	:	681-378-6108

Provider Business Practice Location Address
First Line	:	1236 5TH AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-2207
Country	:	US
Telephone Number	:	681-229-4531
Fax Number	:	681-378-6108

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

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	05/18/2026

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