Provider Demographics
NPI:1366222317
Name:BENNETT, JAMES (PTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 E HERITAGE PKWY STE 3
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:AR
Mailing Address - Zip Code:72730-6018
Mailing Address - Country:US
Mailing Address - Phone:479-334-0014
Mailing Address - Fax:479-334-0013
Practice Address - Street 1:2611 E HERITAGE PKWY STE 3
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-6018
Practice Address - Country:US
Practice Address - Phone:479-334-0014
Practice Address - Fax:479-334-0013
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4812225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty