Provider Demographics
NPI:1902941073
Name:BENNETT, JEFFREY E (LMFT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 TAFT BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-4800
Mailing Address - Country:US
Mailing Address - Phone:940-691-1899
Mailing Address - Fax:940-691-3423
Practice Address - Street 1:4722 TAFT BLVD STE 2
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-4800
Practice Address - Country:US
Practice Address - Phone:940-691-1899
Practice Address - Fax:940-691-3423
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3347101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028976103Medicaid
TX8071BHOtherBLUE CROSS ID NUMBER
TX8071BHOtherBLUE CROSS ID NUMBER