Provider Demographics
NPI:1477730604
Name:JEFFERSON, BONITA JO (MA/SLP)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:JO
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MA/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-9736
Mailing Address - Country:US
Mailing Address - Phone:304-528-5000
Mailing Address - Fax:
Practice Address - Street 1:2850 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1436
Practice Address - Country:US
Practice Address - Phone:304-528-5000
Practice Address - Fax:304-528-5080
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0153738000Medicaid