Provider Demographics
NPI:1578071841
Name:BONNEVILLE, JESSICA ROSE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:BONNEVILLE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:MARIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:111 N CLINTON AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1529
Mailing Address - Country:US
Mailing Address - Phone:616-915-6548
Mailing Address - Fax:
Practice Address - Street 1:3899 OKEMOS RD STE A1
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3666
Practice Address - Country:US
Practice Address - Phone:517-507-5892
Practice Address - Fax:517-258-2951
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional