Provider Demographics
NPI:1578249488
Name:BENNETT, JAZMINE RENEA
Entity Type:Individual
Prefix:
First Name:JAZMINE
Middle Name:RENEA
Last Name:BENNETT
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 1:1321 S LINDEN RD STE SUITE B
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532
Mailing Address - Country:US
Mailing Address - Phone:248-221-2573
Mailing Address - Fax:
Practice Address - Street 1:1321 S LINDEN RD STE SUITE B
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:248-221-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician