Provider Demographics
NPI:1831485523
Name:BENNECHE, ANNETTE JACKSON (LPC, MS, MED)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:JACKSON
Last Name:BENNECHE
Suffix:
Gender:F
Credentials:LPC, MS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NORTH MAIN STREET
Mailing Address - Street 2:DBA: SERVE, LLC
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-3203
Mailing Address - Country:US
Mailing Address - Phone:706-453-7400
Mailing Address - Fax:855-898-5414
Practice Address - Street 1:110 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-1108
Practice Address - Country:US
Practice Address - Phone:706-453-7400
Practice Address - Fax:855-898-5414
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006255101YP2500X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12404855OtherCAQH