Provider Demographics
NPI:1881308393
Name:BENJAMIN, JESSICA LEEANN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEEANN
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 DONNA ST APT D
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5571
Mailing Address - Country:US
Mailing Address - Phone:909-991-9464
Mailing Address - Fax:
Practice Address - Street 1:2525 DONNA ST APT D
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-5571
Practice Address - Country:US
Practice Address - Phone:909-991-9464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00016261488072701238251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV120027855Medicaid