Provider Demographics
NPI:1407342355
Name:BENINGA, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BENINGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 KIMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5037
Mailing Address - Country:US
Mailing Address - Phone:319-234-6419
Mailing Address - Fax:319-226-5898
Practice Address - Street 1:2104 KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5037
Practice Address - Country:US
Practice Address - Phone:319-234-6419
Practice Address - Fax:319-226-5898
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist