Provider Demographics
NPI:1700115334
Name:BENNETT, JAMIE (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
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 4834
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4834
Mailing Address - Country:US
Mailing Address - Phone:307-690-0907
Mailing Address - Fax:
Practice Address - Street 1:640 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-1868
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:307-733-6289
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19278.1031364SP0808X
WY19278363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY19278OtherPSYCHIATRIC NURSE PRACTICONER