Provider Demographics
NPI:1104312347
Name:BENNETT, KALYN
Entity type:Individual
Prefix:
First Name:KALYN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 THE GREENS WAY APT 2732
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 SPRINKLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5448
Practice Address - Country:US
Practice Address - Phone:904-744-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-20-44367103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician