Provider Demographics
NPI:1558004127
Name:BENNETT, ALEXANDER JASON (PHD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JASON
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 BANCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-4301
Mailing Address - Country:US
Mailing Address - Phone:510-725-7215
Mailing Address - Fax:
Practice Address - Street 1:2222 BANCROFT WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-4301
Practice Address - Country:US
Practice Address - Phone:510-725-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34206103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist