Provider Demographics
NPI:1023188745
Name:BONOMO, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BONOMO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 LONG COVE DR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29928-6143
Mailing Address - Country:US
Mailing Address - Phone:843-645-2668
Mailing Address - Fax:866-788-7789
Practice Address - Street 1:380 LONG COVE DR
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29928-6143
Practice Address - Country:US
Practice Address - Phone:843-645-2668
Practice Address - Fax:667-887-7789
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist