Provider Demographics
NPI:1568572782
Name:BRIAR-BONPANE, JENOA (LICSW)
Entity Type:Individual
Prefix:
First Name:JENOA
Middle Name:
Last Name:BRIAR-BONPANE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:PETROLIA
Mailing Address - State:CA
Mailing Address - Zip Code:95558-0047
Mailing Address - Country:US
Mailing Address - Phone:707-599-0310
Mailing Address - Fax:
Practice Address - Street 1:801 CRESCENT WAY
Practice Address - Street 2:#3
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6780
Practice Address - Country:US
Practice Address - Phone:707-599-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00008001104100000X
CALCS259141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker