Provider Demographics
NPI:1033724299
Name:BONACK, JEFFREY A (BA, MDIV)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:BONACK
Suffix:
Gender:M
Credentials:BA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:2669 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2850
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5121-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional