Provider Demographics
NPI:1689440711
Name:BONILLA, JESSE ANTHONY (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:ANTHONY
Last Name:BONILLA
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 APRICOT DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4405
Mailing Address - Country:US
Mailing Address - Phone:714-420-9890
Mailing Address - Fax:
Practice Address - Street 1:2112 E 4TH ST STE 228A
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3840
Practice Address - Country:US
Practice Address - Phone:714-420-9890
Practice Address - Fax:949-749-7433
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028137363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health