Provider Demographics
NPI:1164429320
Name:BENNETT, JEANNE MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9012 WILLOW SPRINGS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-7763
Mailing Address - Country:US
Mailing Address - Phone:502-376-7552
Mailing Address - Fax:502-425-5540
Practice Address - Street 1:1169 EASTERN PKWY STE 2238
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1444
Practice Address - Country:US
Practice Address - Phone:502-376-7552
Practice Address - Fax:502-425-5540
Is Sole Proprietor?:No
Enumeration Date:2005-07-02
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1034103G00000X, 103TC0700X
KY129055103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7020285OtherAETNA
KY89000061Medicaid
KY000000376778OtherANTHEM
KY89000061Medicaid