MEDICARE: MR. JERRAD LEE BENTON LMT, MMP

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	225700000X	Massage Therapist	2001031193	MO

General Provider Information

NPI Number	:	1891211017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRAD LEE BENTON LMT, MMP

Provider Business Mailing Address
First Line	:	2430 TELLICHERRY DR.
Second Line	:	300A
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-3108
Country	:	US
Telephone Number	:	314-600-6293
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 TELLICHERRY DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-3108
Country	:	US
Telephone Number	:	314-600-6293
Fax Number	:

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

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	07/21/2022

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