Provider Demographics
NPI:1659881621
Name:BENNETT, JERRIE DAWN
Entity Type:Individual
Prefix:
First Name:JERRIE
Middle Name:DAWN
Last Name: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 1:41 MONTEBELLO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1366
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-542-9638
Practice Address - Street 1:417 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-3126
Practice Address - Country:US
Practice Address - Phone:719-846-4416
Practice Address - Fax:719-846-6408
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1636886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse