Provider Demographics
NPI:1053737080
Name:BENITEZ, JESSICA (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CABERNET DR
Mailing Address - Street 2:#3
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03303-1042
Mailing Address - Country:US
Mailing Address - Phone:313-330-0776
Mailing Address - Fax:
Practice Address - Street 1:239 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7504
Practice Address - Country:US
Practice Address - Phone:603-224-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272358363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology