Provider Demographics
NPI:1104058163
Name:BENNETT, JARED (CCC/SLP)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 W 10550 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8597
Mailing Address - Country:US
Mailing Address - Phone:801-253-1023
Mailing Address - Fax:
Practice Address - Street 1:1098 W 10550 S
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8597
Practice Address - Country:US
Practice Address - Phone:801-253-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5223035-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist