Provider Demographics
NPI:1508395294
Name:BENNETT, JAMIE MICHAEL (LCSWA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:MICHAEL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21858 OAK POINTE LN APT C
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5955
Mailing Address - Country:US
Mailing Address - Phone:830-282-9035
Mailing Address - Fax:
Practice Address - Street 1:EBH 1BCT 5TH ARMORED DIVISION DRIVE
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0097841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical