Provider Demographics
NPI:1790666915
Name:BENTON, JAQUINCIA DOMINIQUE
Entity type:Individual
Prefix:
First Name:JAQUINCIA
Middle Name:DOMINIQUE
Last Name:BENTON
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 1:14174 LEAYN CT
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-8836
Mailing Address - Country:US
Mailing Address - Phone:225-441-0162
Mailing Address - Fax:
Practice Address - Street 1:10510 JOOR RD STE 300A
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-3925
Practice Address - Country:US
Practice Address - Phone:225-960-2403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician