Provider Demographics
NPI:1043613516
Name:BONILLA, JESSICA LORENA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LORENA
Last Name:BONILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 LANDING MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1100
Mailing Address - Country:US
Mailing Address - Phone:631-626-6377
Mailing Address - Fax:
Practice Address - Street 1:156 LANDING MEADOW RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1100
Practice Address - Country:US
Practice Address - Phone:631-626-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist