MEDICARE: JASON EUGENE BENNETT MSPT SCS ATC

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	225100000X	Physical Therapist	119668	MO
2	2255A2300X	Athletic Trainer	2008003299	MO

General Provider Information

NPI Number	:	1609987650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON EUGENE BENNETT MSPT SCS ATC

Provider Business Mailing Address
First Line	:	502 LEONARD AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-1538
Country	:	US
Telephone Number	:	314-459-4114
Fax Number	:

Provider Business Practice Location Address
First Line	:	3437 CAROLINE ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1111
Country	:	US
Telephone Number	:	314-977-8652
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/13/2012

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