Provider Demographics
NPI:1598208357
Name:BENNETT, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8070 W RUSSELL RD
Mailing Address - Street 2:1092
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1549
Mailing Address - Country:US
Mailing Address - Phone:410-205-5292
Mailing Address - Fax:
Practice Address - Street 1:8070 W RUSSELL RD
Practice Address - Street 2:1092
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-1549
Practice Address - Country:US
Practice Address - Phone:410-205-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11-0109283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital