Provider Demographics
NPI:1891211017
Name:BENTON, JERRAD LEE (LMT, MMP)
Entity Type:Individual
Prefix:MR
First Name:JERRAD
Middle Name:LEE
Last Name:BENTON
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 TELLICHERRY DR.
Mailing Address - Street 2:300A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-3108
Mailing Address - Country:US
Mailing Address - Phone:314-600-6293
Mailing Address - Fax:
Practice Address - Street 1:2430 TELLICHERRY DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3108
Practice Address - Country:US
Practice Address - Phone:314-600-6293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031193225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist