Provider Demographics
NPI:1477758696
Name:BENTON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BENTON
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 1:11107 ULYSSES ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4264
Mailing Address - Country:US
Mailing Address - Phone:763-333-7733
Mailing Address - Fax:763-333-7711
Practice Address - Street 1:11107 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4263
Practice Address - Country:US
Practice Address - Phone:763-333-7725
Practice Address - Fax:763-333-7711
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 165945-0163W00000X
MN20111983363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse