Provider Demographics
NPI:1679706113
Name:BONATAKIS, JESSICA KATHLEEN (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KATHLEEN
Last Name:BONATAKIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KATHLEEN
Other - Last Name:BONATAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:22 NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2732
Practice Address - Country:US
Practice Address - Phone:717-531-8338
Practice Address - Fax:717-531-6250
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018803103TC2200X
KY129694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical