Provider Demographics
NPI:1073581609
Name:BENNER, JETTA MELINDA (PT)
Entity Type:Individual
Prefix:MRS
First Name:JETTA
Middle Name:MELINDA
Last Name:BENNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 UPTOWN BLVD
Mailing Address - Street 2:SUITE 1105
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3507
Mailing Address - Country:US
Mailing Address - Phone:469-272-3129
Mailing Address - Fax:469-272-3145
Practice Address - Street 1:638 UPTOWN BLVD
Practice Address - Street 2:SUITE 1105
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3507
Practice Address - Country:US
Practice Address - Phone:469-272-3129
Practice Address - Fax:469-272-3145
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11068052251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T1319OtherBCBS
TX8T1319OtherBCBS
TX324826YWRGMedicare PIN