Provider Demographics
NPI:1114266731
Name:BENNETT, CHRISTAN LATONYA (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:CHRISTAN
Middle Name:LATONYA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:MS
Other - First Name:CHRISTAN
Other - Middle Name:LATONYA
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1589 MOUNTAIN LAKE DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-5548
Mailing Address - Country:US
Mailing Address - Phone:904-337-9073
Mailing Address - Fax:904-337-4448
Practice Address - Street 1:1589 MOUNTAIN LAKE DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-5548
Practice Address - Country:US
Practice Address - Phone:904-337-9073
Practice Address - Fax:904-337-4448
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL160994624104100000X
FLSW137121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029573621Medicaid