Basic Information
| Provider Information | |||||||||
| NPI: | 1881888931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2513 SHALLOWFORD RD | ||||||||
| Address2: | BLDG 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300666809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705163500 | ||||||||
| FaxNumber: | 7705163500 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 CHEROKEE ST NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301442085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704265666 | ||||||||
| FaxNumber: | 7704269212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 003147 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.