Provider Demographics
NPI:1265410898
Name:BENNETT, JEFFREY I (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:I
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-7578
Mailing Address - Fax:217-545-1884
Practice Address - Street 1:901 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4833
Practice Address - Country:US
Practice Address - Phone:217-545-8229
Practice Address - Fax:217-545-2275
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0800652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080065Medicaid
ILL98687Medicare PIN
IL256510Medicare PIN