Provider Demographics
NPI:1760805402
Name:BENNETT, LISHON
Entity Type:Individual
Prefix:MS
First Name:LISHON
Middle Name:
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 1:4570 SAIT JOHNS AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210
Mailing Address - Country:US
Mailing Address - Phone:904-389-5231
Mailing Address - Fax:
Practice Address - Street 1:4570 SAIT JOHNS AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-389-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL591283134251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management