Provider Demographics
NPI:1538826573
Name:JEB BENNETT LCSW
Entity type:Organization
Organization Name:JEB BENNETT LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:303-946-0236
Mailing Address - Street 1:800 LARAMIE BLVD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-4785
Mailing Address - Country:US
Mailing Address - Phone:303-946-0236
Mailing Address - Fax:
Practice Address - Street 1:800 LARAMIE BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4785
Practice Address - Country:US
Practice Address - Phone:303-946-0236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-24
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty