Provider Demographics
NPI:1326022963
Name:BONIFAS, JANE M (PHD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:BONIFAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13731 CONVERSE ROSELM RD
Mailing Address - Street 2:
Mailing Address - City:VENEDOCIA
Mailing Address - State:OH
Mailing Address - Zip Code:45894-9532
Mailing Address - Country:US
Mailing Address - Phone:419-695-2194
Mailing Address - Fax:
Practice Address - Street 1:13731 CONVERSE ROSELM RD
Practice Address - Street 2:
Practice Address - City:VENEDOCIA
Practice Address - State:OH
Practice Address - Zip Code:45894-9532
Practice Address - Country:US
Practice Address - Phone:419-695-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5315103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
680012644OtherANTHEM RR
OH2054360Medicaid
S57822Medicare UPIN
680012644OtherANTHEM RR