Provider Demographics
NPI:1518195031
Name:BENNETT, JILL MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHD
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 1866
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75456-1866
Mailing Address - Country:US
Mailing Address - Phone:903-575-1330
Mailing Address - Fax:903-577-9156
Practice Address - Street 1:511 W 1ST ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-4336
Practice Address - Country:US
Practice Address - Phone:903-575-1330
Practice Address - Fax:903-577-9156
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20261103TC1900X
TX201003106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1796567-01Medicaid