Provider Demographics
NPI:1376970558
Name:BENKO, JONATHAN COLEMAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:COLEMAN
Last Name:BENKO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 542
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-0542
Mailing Address - Country:US
Mailing Address - Phone:831-424-3500
Mailing Address - Fax:
Practice Address - Street 1:1510 CAPITOLA RD
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2912
Practice Address - Country:US
Practice Address - Phone:831-427-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW81650104100000X
CA101YM0800X
CAASW 68409104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#