Provider Demographics
NPI:1053776948
Name:BENEDICT, JESSI (ATC,LAT)
Entity type:Individual
Prefix:
First Name:JESSI
Middle Name:
Last Name:BENEDICT
Suffix:
Gender:F
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 LAKE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-2112
Mailing Address - Country:US
Mailing Address - Phone:904-910-2167
Mailing Address - Fax:
Practice Address - Street 1:346 LAKE RIDGE LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-2112
Practice Address - Country:US
Practice Address - Phone:904-910-2167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002513A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer