Provider Demographics
NPI:1699163170
Name:BENNETT, JESSICA (CNM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3679 S SHORTLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-8617
Mailing Address - Country:US
Mailing Address - Phone:208-391-3995
Mailing Address - Fax:
Practice Address - Street 1:3679 S SHORTLEAF AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-8617
Practice Address - Country:US
Practice Address - Phone:208-391-3995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53218367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1699163170Medicaid