Provider Demographics
NPI:1134461585
Name:BONNICHSEN, JENNA
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:
Last Name:BONNICHSEN
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 1:691 JOHN WESLEY DOBBS AVE NE
Mailing Address - Street 2:UNIT Q
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3602 SE 28TH PL
Practice Address - Street 2:APT 4
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3084
Practice Address - Country:US
Practice Address - Phone:701-793-1109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health