Provider Demographics
NPI:1598483661
Name:BENITEZ, JENNIFFER
Entity Type:Individual
Prefix:
First Name:JENNIFFER
Middle Name:
Last Name:BENITEZ
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 1:3038 72ND ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1417
Mailing Address - Country:US
Mailing Address - Phone:317-474-3683
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:718-963-7272
Practice Address - Fax:718-963-6451
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP115241208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP115241OtherNEW YORK EDUCATION DEPARTMENT DIVISION OF PROFESSIONAL LICENSING SERVICES