Provider Demographics
NPI:1962066159
Name:BENTON, JEFFREY TODD (MED, EDS)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:TODD
Last Name:BENTON
Suffix:
Gender:M
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH MAIN ST PO BOX 1549
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434
Mailing Address - Country:US
Mailing Address - Phone:757-925-6764
Mailing Address - Fax:
Practice Address - Street 1:200 FOREST GLEN DR
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6714
Practice Address - Country:US
Practice Address - Phone:757-925-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000142103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool