Provider Demographics
NPI:1558010157
Name:BENORDEN, JENNIFER L (CMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BENORDEN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-1205
Mailing Address - Country:US
Mailing Address - Phone:650-796-1924
Mailing Address - Fax:
Practice Address - Street 1:2041 BANCROFT WAY STE 303
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1406
Practice Address - Country:US
Practice Address - Phone:650-796-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86084225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist