Provider Demographics
NPI:1548895485
Name:BENNETT, JASON ANTHONY
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANTHONY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 BAYLOR BLVD
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-3420
Mailing Address - Country:US
Mailing Address - Phone:432-271-8779
Mailing Address - Fax:
Practice Address - Street 1:708 BAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-3420
Practice Address - Country:US
Practice Address - Phone:432-271-8779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX879644163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse