Provider Demographics
NPI:1477800142
Name:CANTRELL, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CANTRELL
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:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:JACKS CREEK
Mailing Address - State:TN
Mailing Address - Zip Code:38347-0078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 DEVONSHIRE SQ STE 7
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2267
Practice Address - Country:US
Practice Address - Phone:731-660-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-12
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5299225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant