Provider Demographics
NPI: | 1487640819 |
---|---|
Name: | BENNISON, JILL M (CPNP-PC) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | JILL |
Middle Name: | M |
Last Name: | BENNISON |
Suffix: | |
Gender: | F |
Credentials: | CPNP-PC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 700 CHILDRENS DR |
Mailing Address - Street 2: | |
Mailing Address - City: | COLUMBUS |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43205-2664 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 614-722-2461 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 479 PARSONS AVE |
Practice Address - Street 2: | |
Practice Address - City: | COLUMBUS |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43215-5577 |
Practice Address - Country: | US |
Practice Address - Phone: | 614-722-5136 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-09-21 |
Last Update Date: | 2022-02-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | APRN.CNP.06567 | 363LP2300X, 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 3032024 | Medicaid | |
OH | H195090 | Other | CGS-MEDICARE |