Provider Demographics
NPI:1790110666
Name:BENOIT, JENNA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:BENOIT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 N SANDBURG TER
Mailing Address - Street 2:APT 1503
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8253
Mailing Address - Country:US
Mailing Address - Phone:248-890-5063
Mailing Address - Fax:
Practice Address - Street 1:2400 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2021
Practice Address - Country:US
Practice Address - Phone:773-270-5600
Practice Address - Fax:773-360-7378
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant