Provider Demographics
NPI:1609361559
Name:BENDA, JASMINE FAITH (RBT-18-58051)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:FAITH
Last Name:BENDA
Suffix:
Gender:F
Credentials:RBT-18-58051
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N PACIFIC COAST HWY STE 1400
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5602
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:
Practice Address - Street 1:3111 124TH AVE NW STE 150
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4573
Practice Address - Country:US
Practice Address - Phone:763-272-5877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1-23-68803103K00000X
IL18-58051106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst