Provider Demographics
NPI:1801050869
Name:JENNETT, BENJAMIN W (LCSW)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:W
Last Name:JENNETT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-5326
Mailing Address - Country:US
Mailing Address - Phone:805-434-3829
Mailing Address - Fax:805-434-3839
Practice Address - Street 1:71 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-5326
Practice Address - Country:US
Practice Address - Phone:805-434-3829
Practice Address - Fax:805-434-3839
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000091541041C0700X
CALCS 217501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS 21750OtherCA BOARD OF BEHAVIROL SCIENCES
WALW00009154OtherSTATE MEDICAL LICENSE