Provider Demographics
NPI:1477074326
Name:BENTHAM, JACK E
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:BENTHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 ESPLANADE CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-4010
Mailing Address - Country:US
Mailing Address - Phone:817-219-4599
Mailing Address - Fax:817-964-3380
Practice Address - Street 1:4710 ESPLANADE CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-4010
Practice Address - Country:US
Practice Address - Phone:817-219-4599
Practice Address - Fax:817-219-4599
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36233103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling