Provider Demographics
NPI:1093825101
Name:BENACKER, JEAN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:BENACKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 S PROSPECT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7050
Mailing Address - Country:US
Mailing Address - Phone:217-352-9206
Mailing Address - Fax:217-352-9186
Practice Address - Street 1:1701 S PROSPECT AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7050
Practice Address - Country:US
Practice Address - Phone:217-352-9206
Practice Address - Fax:217-352-9186
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003677103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical