Provider Demographics
NPI:1134193758
Name:BENTZ, JON E (PHD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:BENTZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3172
Mailing Address - Fax:717-544-3229
Practice Address - Street 1:2100 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2644
Practice Address - Country:US
Practice Address - Phone:717-544-3172
Practice Address - Fax:717-544-3229
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004295L103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001965644Medicaid
PA001965644Medicaid