Provider Demographics
NPI:1851328835
Name:BENJAMIN, JEANNETTE (MD)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 EAST 11TH STREET SUITE 101
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-981-5970
Mailing Address - Fax:909-981-5980
Practice Address - Street 1:811 E. 11TH STREET SUITE 101
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-981-5970
Practice Address - Fax:909-981-5980
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39542173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A289070Medicaid
CA00A289070Medicaid
CA00A289070Medicare ID - Type Unspecified