Provider Demographics
NPI:1962186718
Name:BENNETT, JUNE MARIE
Entity type:Individual
Prefix:
First Name:JUNE
Middle Name:MARIE
Last Name:BENNETT
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 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3680 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1466
Practice Address - Country:US
Practice Address - Phone:541-523-4049
Practice Address - Fax:541-523-4062
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPENDING171M00000X
OR23-QMHA-R-3992171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3305578OtherDRIVERS LICENSE