Provider Demographics
NPI:1811297120
Name:BENNETT, JEREMY A (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1550
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7127 HIGHWAY 98 WEST
Practice Address - Street 2:SUITE 40
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-261-1550
Practice Address - Fax:601-268-2530
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01206663OtherRAILROAD MEDICARE
MS0463784OtherCIGNA
MS9007864OtherAETNA
MS00237896Medicaid
MS3451245OtherUNITED HEALTHCARE
MS302I654952Medicare PIN