Provider Demographics
NPI:1194827816
Name:BENICH, JONATHAN A (MSPT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:A
Last Name:BENICH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 ALPINE BLVD.
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3950
Mailing Address - Country:US
Mailing Address - Phone:619-445-3168
Mailing Address - Fax:619-445-5368
Practice Address - Street 1:2549 ALPINE BLVD.
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3950
Practice Address - Country:US
Practice Address - Phone:619-445-3168
Practice Address - Fax:619-445-5368
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0292430Medicaid
WPT29243AMedicare UPIN