Provider Demographics
NPI:1013142769
Name:BENTON, JILL CHRISTINE (CRNA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:CHRISTINE
Last Name:BENTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 RANDOL AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2320
Mailing Address - Country:US
Mailing Address - Phone:573-382-4785
Mailing Address - Fax:
Practice Address - Street 1:1953 RANDOL AVE
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2320
Practice Address - Country:US
Practice Address - Phone:573-382-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2015-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004007343367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered