Provider Demographics
NPI:1609927219
Name:BENTON, JENNIFER M (PH D)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BENTON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 S HARVARD AVE
Mailing Address - Street 2:SUITE 470
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3055
Mailing Address - Country:US
Mailing Address - Phone:918-392-4866
Mailing Address - Fax:918-392-4867
Practice Address - Street 1:4520 S HARVARD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2925
Practice Address - Country:US
Practice Address - Phone:918-743-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical