Provider Demographics
NPI:1659042281
Name:BENTLEY, JALYNN
Entity Type:Individual
Prefix:
First Name:JALYNN
Middle Name:
Last Name:BENTLEY
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 1:3464 STACKHOUSE PL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4712
Mailing Address - Country:US
Mailing Address - Phone:706-294-9074
Mailing Address - Fax:
Practice Address - Street 1:3464 STACKHOUSE PL
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4712
Practice Address - Country:US
Practice Address - Phone:706-294-9074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician