Provider Demographics
NPI:1982033676
Name:BENNETT, JAKE (QMHA)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 KAEN RD STE 367
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-742-5979
Practice Address - Street 1:1002 LIBRARY CT
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4066
Practice Address - Country:US
Practice Address - Phone:503-655-8264
Practice Address - Fax:503-655-8428
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health