Provider Demographics
NPI:1659086775
Name:BENNETT, JESSE THOMAS (LCASA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:THOMAS
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 GRESHAM LAKE RD STE 113
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4131
Mailing Address - Country:US
Mailing Address - Phone:919-977-5993
Mailing Address - Fax:
Practice Address - Street 1:3209 GRESHAM LAKE RD STE 113
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4131
Practice Address - Country:US
Practice Address - Phone:919-977-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25008101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC25008Medicaid