Provider Demographics
NPI:1639828882
Name:GARDNER BENNETT, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GARDNER BENNETT
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 1:17 HOSPITAL DRIVE
Mailing Address - Street 2:BUSHNELL MEDICA
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662
Mailing Address - Country:US
Mailing Address - Phone:315-705-6564
Mailing Address - Fax:315-705-6567
Practice Address - Street 1:17 HOSPITAL DRIVE
Practice Address - Street 2:BUSHNELL MEDICA
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662
Practice Address - Country:US
Practice Address - Phone:315-705-6564
Practice Address - Fax:315-705-6567
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)