Provider Demographics
NPI:1184030496
Name:BENTLEY, JENNIFER NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1000 DEPT 978
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-758-9900
Mailing Address - Fax:901-752-2335
Practice Address - Street 1:3876 NEW COVINGTON PIKE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128
Practice Address - Country:US
Practice Address - Phone:901-377-2711
Practice Address - Fax:901-382-9051
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10589208000000X
TN55517208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2367480Medicaid