Provider Demographics
NPI:1770325672
Name:BENNETT, JACKLYN BROOKE (CRNP)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:BROOKE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:ELLWOOD CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16117-3234
Mailing Address - Country:US
Mailing Address - Phone:724-714-8439
Mailing Address - Fax:
Practice Address - Street 1:1035 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:ELLWOOD CITY
Practice Address - State:PA
Practice Address - Zip Code:16117-3234
Practice Address - Country:US
Practice Address - Phone:724-714-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029854363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily