MEDICARE: BRYNN JAKLYN BENNETT

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	106S00000X	Behavior Technician	900000363917	MI

General Provider Information

NPI Number	:	1699621995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYNN JAKLYN BENNETT

Provider Business Mailing Address
First Line	:	509 WACHTEL AVE
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-2338
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 SPRING ST STE 4
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-2881
Country	:	US
Telephone Number	:	231-268-0007
Fax Number	:

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

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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