Provider Demographics
NPI:1750138574
Name:BENJAMIN, JONATHAN LIVINGSTON
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LIVINGSTON
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7602 GUNNERS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-3881
Mailing Address - Country:US
Mailing Address - Phone:615-917-7285
Mailing Address - Fax:
Practice Address - Street 1:7602 GUNNERS LANDING DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3881
Practice Address - Country:US
Practice Address - Phone:615-917-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN094847770172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver