Provider Demographics
NPI:1033667803
Name:BENNETT, JESSICA LEE (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LEE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 N ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1152
Mailing Address - Country:US
Mailing Address - Phone:419-708-6875
Mailing Address - Fax:
Practice Address - Street 1:134 N ROSE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-1152
Practice Address - Country:US
Practice Address - Phone:419-708-6875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA007972255A2300X
OHAT.0042562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer