Provider Demographics
NPI:1629797733
Name:BONFANTE, JAMIE LEE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:BONFANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 WALLIS RD APT 205
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33413-1913
Mailing Address - Country:US
Mailing Address - Phone:754-217-9635
Mailing Address - Fax:
Practice Address - Street 1:1765 SW CAPTAINS PL
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1747
Practice Address - Country:US
Practice Address - Phone:772-266-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-22-239300106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician