Provider Demographics
NPI:1336320258
Name:BENNETT, JASON D (MS-SLP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 S BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-5656
Mailing Address - Country:US
Mailing Address - Phone:920-803-1617
Mailing Address - Fax:920-803-1622
Practice Address - Street 1:2131 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-5656
Practice Address - Country:US
Practice Address - Phone:920-803-1617
Practice Address - Fax:920-803-1622
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2963-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41813000Medicaid
WI41813000Medicaid