Provider Demographics
NPI:1659873586
Name:BENTON, JASON PAUL (LPC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PAUL
Last Name:BENTON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 SCOGGINS DR
Mailing Address - Street 2:
Mailing Address - City:DEMOREST
Mailing Address - State:GA
Mailing Address - Zip Code:30535-5354
Mailing Address - Country:US
Mailing Address - Phone:706-894-3700
Mailing Address - Fax:
Practice Address - Street 1:1090 FOUNDERS BLVD STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6163
Practice Address - Country:US
Practice Address - Phone:706-549-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007064101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor