Provider Demographics
NPI:1407426992
Name:BENAVIDEZ, JAMIE DANIELLE (R1426050421)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:DANIELLE
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:R1426050421
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95633-0871
Mailing Address - Country:US
Mailing Address - Phone:530-499-0186
Mailing Address - Fax:
Practice Address - Street 1:5607 MOUNT MURPHY ROAD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633-9563
Practice Address - Country:US
Practice Address - Phone:530-497-4583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1426050421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)