Provider Demographics
NPI:1790955334
Name:J BENNETT GROUP PSC
Entity Type:Organization
Organization Name:J BENNETT GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:502-376-7552
Mailing Address - Street 1:1603 STEVENS AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1087
Mailing Address - Country:US
Mailing Address - Phone:502-376-7552
Mailing Address - Fax:502-425-5540
Practice Address - Street 1:1169 EASTERN PKWY STE 2238
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1444
Practice Address - Country:US
Practice Address - Phone:502-376-7552
Practice Address - Fax:502-425-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1034103G00000X, 103TC0700X
KY129055103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89900344Medicaid
KY000000376780OtherANTHEM
KY50107908OtherPASSPORT HEALTH
KY7944828OtherAETNA
KY7944828OtherAETNA