Provider Demographics
NPI:1134412596
Name:BENNETT, JACKIE MARIE (LMP, CLT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LMP, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10508 123RD STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2626
Mailing Address - Country:US
Mailing Address - Phone:253-209-6276
Mailing Address - Fax:
Practice Address - Street 1:10508 123RD STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2626
Practice Address - Country:US
Practice Address - Phone:253-209-6276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022947174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist