Basic Information
| Provider Information | |||||||||
| NPI: | 1801050869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNETT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934655326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054343829 | ||||||||
| FaxNumber: | 8054343839 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934655326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054343829 | ||||||||
| FaxNumber: | 8054343839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00009154 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCS 21750 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LCS 21750 | 01 | CA | CA BOARD OF BEHAVIROL SCIENCES | OTHER | LW00009154 | 01 | WA | STATE MEDICAL LICENSE | OTHER |