Provider Demographics
NPI:1952477424
Name:BENSON, JON LOUIS (PSY D)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:LOUIS
Last Name:BENSON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:STE 215
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2442
Mailing Address - Country:US
Mailing Address - Phone:503-252-9690
Mailing Address - Fax:503-252-2720
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:STE 215
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2442
Practice Address - Country:US
Practice Address - Phone:503-252-9690
Practice Address - Fax:503-252-2720
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1080103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
068WDBBQAMedicare ID - Type Unspecified
R01186Medicare UPIN