Provider Demographics
NPI:1043523343
Name:BENNETT, JENNA LEE (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LEE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 N MAGDALEN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-5434
Mailing Address - Country:US
Mailing Address - Phone:325-944-2561
Mailing Address - Fax:325-653-4218
Practice Address - Street 1:242 N MAGDALEN ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5434
Practice Address - Country:US
Practice Address - Phone:325-944-2561
Practice Address - Fax:325-653-4218
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO686104100000X
TX640341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38007371Medicaid
CO38007371Medicaid