Provider Demographics
NPI:1528507126
Name:BENCIVENGA, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BENCIVENGA
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 1:5 REVERE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1566
Mailing Address - Country:US
Mailing Address - Phone:941-485-0121
Mailing Address - Fax:941-485-0591
Practice Address - Street 1:417 COMMERCIAL CT STE C
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1655
Practice Address - Country:US
Practice Address - Phone:941-485-0121
Practice Address - Fax:941-485-0591
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18774101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health