Provider Demographics
NPI:1164555009
Name:BONNER, JACOB ANDREW (DC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:BONNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COLLEGIATE DR
Mailing Address - Street 2:#900
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-1494
Mailing Address - Country:US
Mailing Address - Phone:515-447-5256
Mailing Address - Fax:
Practice Address - Street 1:201 N COLLEGIATE DR
Practice Address - Street 2:#900
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-1494
Practice Address - Country:US
Practice Address - Phone:515-447-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06956111N00000X
TX11474111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06956OtherLICENSE NUMBER
TX11474OtherSTATE LICENSE