Provider Demographics
NPI:1316317340
Name:BENNETT, JERSIAH
Entity type:Individual
Prefix:
First Name:JERSIAH
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 W CRAIG RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-5124
Mailing Address - Country:US
Mailing Address - Phone:702-693-7117
Mailing Address - Fax:
Practice Address - Street 1:3053 W CRAIG RD
Practice Address - Street 2:SUITE E
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5124
Practice Address - Country:US
Practice Address - Phone:702-639-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst