Basic Information
Provider Information | |||||||||
NPI: | 1477564946 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENN | ||||||||
FirstName: | JAMILA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1381 UNIVERSITY ST | ||||||||
Address2: |   | ||||||||
City: | HEALDSBURG | ||||||||
State: | CA | ||||||||
PostalCode: | 954483314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074335494 | ||||||||
FaxNumber: | 7074318649 | ||||||||
Practice Location | |||||||||
Address1: | 8465 OLD REDWOOD HWY STE 320 | ||||||||
Address2: |   | ||||||||
City: | WINDSOR | ||||||||
State: | CA | ||||||||
PostalCode: | 95492 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7074335494 | ||||||||
FaxNumber: | 7078370119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 06/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1419 | VI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 036116197 | IL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | C138333 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 036116197 | 05 | IL |   | MEDICAID |