Provider Demographics
NPI:1033384771
Name:BENNETT, JASON K
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:K
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SHADOW WOOD CV
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901
Mailing Address - Country:US
Mailing Address - Phone:662-226-4029
Mailing Address - Fax:
Practice Address - Street 1:140 SHADOW WOOD CV
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901
Practice Address - Country:US
Practice Address - Phone:662-226-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-09543183500000X
LA15124183500000X
TX32759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist