Provider Demographics
NPI:1568043727
Name:BENTON, JALA RAQUEL
Entity Type:Individual
Prefix:
First Name:JALA
Middle Name:RAQUEL
Last Name:BENTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2512
Mailing Address - Country:US
Mailing Address - Phone:419-371-6054
Mailing Address - Fax:
Practice Address - Street 1:1536 CRAYTON AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-3722
Practice Address - Country:US
Practice Address - Phone:419-371-6054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide