Provider Demographics
NPI:1043581754
Name:BENNETT, JEFFREY (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
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 1:5068 GATES DR
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-9636
Mailing Address - Country:US
Mailing Address - Phone:704-483-1662
Mailing Address - Fax:
Practice Address - Street 1:2826 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1386
Practice Address - Country:US
Practice Address - Phone:704-366-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17242255A2300X
SC13052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer