Provider Demographics
NPI:1912300716
Name:JACKSON, BENITA
Entity Type:Individual
Prefix:MISS
First Name:BENITA
Middle Name:
Last Name:JACKSON
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 1:6102 W TOWNLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4518
Mailing Address - Country:US
Mailing Address - Phone:623-915-9363
Mailing Address - Fax:
Practice Address - Street 1:6102 W TOWNLEY AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4518
Practice Address - Country:US
Practice Address - Phone:623-915-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management