Provider Demographics
NPI:1386654424
Name:BENTSON, JESSICA ANNE (DPM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:BENTSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4510
Mailing Address - Country:US
Mailing Address - Phone:701-258-8120
Mailing Address - Fax:701-222-0229
Practice Address - Street 1:525 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4510
Practice Address - Country:US
Practice Address - Phone:701-258-8120
Practice Address - Fax:701-222-0229
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND49213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12003Medicaid
NDN22212Medicare PIN
U90829Medicare UPIN