Provider Demographics
NPI:1215297353
Name:BENNETT, GERRY JO (RN)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:JO
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2486 BROOKGLEN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-7148
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-584-2557
Practice Address - Street 1:DEPARTMENT OF VETERANS AFFAIRS
Practice Address - Street 2:500 FOOTHILL BLVD
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2557
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT212587-3102163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT212587-3102OtherDOPL ACTIVE LICENSE