Provider Demographics
NPI:1609350578
Name:BENJAMIN, JEAN (RN)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:210 E OLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1434
Mailing Address - Country:US
Mailing Address - Phone:608-807-1428
Mailing Address - Fax:608-807-1429
Practice Address - Street 1:210 E OLIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1434
Practice Address - Country:US
Practice Address - Phone:608-807-1428
Practice Address - Fax:608-808-1429
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI114257-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI114257-30OtherRN LICENSE