Provider Demographics
NPI:1629243142
Name:BENTON, JENNIFER MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BENTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:REECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6475 CHRISTIE AVE STE 135
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2268
Mailing Address - Country:US
Mailing Address - Phone:510-450-0422
Mailing Address - Fax:
Practice Address - Street 1:6475 CHRISTIE AVE STE 135
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608
Practice Address - Country:US
Practice Address - Phone:510-450-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36506225100000X
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist