1831485523 NPI number — MS. ANNETTE JACKSON BENNECHE LPC, M.S., M.ED.

Table of content: MS. ANNETTE JACKSON BENNECHE LPC, M.S., M.ED. (NPI 1831485523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831485523 NPI number — MS. ANNETTE JACKSON BENNECHE LPC, M.S., M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNECHE
Provider First Name:
ANNETTE
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, M.S., M.ED.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831485523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 NORTH MAIN STREET
Provider Second Line Business Mailing Address:
DBA: SERVE, LLC
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30642-3203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-453-7400
Provider Business Mailing Address Fax Number:
855-898-5414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30642-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-453-7400
Provider Business Practice Location Address Fax Number:
855-898-5414
Provider Enumeration Date:
06/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  006255 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171M00000X , with the licence number: 006255 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12404855 . This is a "CAQH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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