Provider Demographics
NPI:1447281159
Name:BENNETT, JEFFERY RAY (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:RAY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 S JOHN ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1413
Mailing Address - Country:US
Mailing Address - Phone:815-584-3808
Mailing Address - Fax:
Practice Address - Street 1:103 S JOHN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1413
Practice Address - Country:US
Practice Address - Phone:815-584-3808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL777591Medicare PIN
ILT38950Medicare UPIN