Provider Demographics
NPI:1124366927
Name:BENNETT, JENNIFER (MS, LP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 WAYZATA BLVD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2031
Mailing Address - Country:US
Mailing Address - Phone:952-446-7933
Mailing Address - Fax:
Practice Address - Street 1:11900 WAYZATA BLVD
Practice Address - Street 2:SUITE 214
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2031
Practice Address - Country:US
Practice Address - Phone:952-446-7933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3253103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist