Basic Information
| Provider Information | |||||||||
| NPI: | 1184030496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1000 DEPT 978 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017589900 | ||||||||
| FaxNumber: | 9017522335 | ||||||||
| Practice Location | |||||||||
| Address1: | 3876 NEW COVINGTON PIKE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013772711 | ||||||||
| FaxNumber: | 9013829051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E-10589 | AR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 55517 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 2367480 | 05 | LA | MEDICAID |