MEDICARE: MR. JONATHAN ANTONIO BENNETT JR. MA, LPC-A

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	101YM0800X	Mental Health Counselor	6918	SC

General Provider Information

NPI Number	:	1821572140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN ANTONIO BENNETT JR. MA, LPC-A

Provider Business Mailing Address
First Line	:	1909 CAPELLA CT
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29527-8200
Country	:	US
Telephone Number	:	843-450-4055
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 19TH AVE N # 202B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3249
Country	:	US
Telephone Number	:	843-504-6912
Fax Number	:	843-326-4848

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

Provider Enumeration Date	:	09/21/2018
Last Update Date	:	05/07/2026

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