Provider Demographics
NPI:1750084679
Name:BENNION, JESSICA KATHLEEN (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KATHLEEN
Last Name:BENNION
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KATHLEEN
Other - Last Name:BURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1100 E OSBORN RD APT 346
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5271
Mailing Address - Country:US
Mailing Address - Phone:435-890-8687
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD # M260
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-977-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program