Provider Demographics
NPI:1447264551
Name:BENNETT, JASON DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:DAVID
Last Name:BENNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4850 ENCORE BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-6013
Mailing Address - Country:US
Mailing Address - Phone:989-772-1704
Mailing Address - Fax:989-773-9406
Practice Address - Street 1:4850 ENCORE BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-6013
Practice Address - Country:US
Practice Address - Phone:989-772-1704
Practice Address - Fax:989-773-9406
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist