Provider Demographics
NPI:1821572140
Name:BENNETT, JONATHAN ANTONIO JR (MA, LPC-A)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ANTONIO
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:MA, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 CAPELLA CT
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29527-8200
Mailing Address - Country:US
Mailing Address - Phone:843-450-4055
Mailing Address - Fax:
Practice Address - Street 1:110 YE OLDE KINGS HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4384
Practice Address - Country:US
Practice Address - Phone:843-663-0770
Practice Address - Fax:843-663-0772
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6918101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health