Provider Demographics
NPI:1851693931
Name:BONILLA, JASON
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 WATERS PLACE SUITE 501
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-409-9444
Mailing Address - Fax:718-409-0236
Practice Address - Street 1:1250 WATERS PLACE SUITE 501
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-409-9444
Practice Address - Fax:718-409-0236
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist