Provider Demographics
NPI:1477965853
Name:BENTON, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
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 1:34394 NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:ANABEL
Mailing Address - State:MO
Mailing Address - Zip Code:63431-2702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 S MORLEY ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2123
Practice Address - Country:US
Practice Address - Phone:660-269-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014014453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional