Provider Demographics
NPI:1942821426
Name:BONNER, JESSICA DENA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DENA
Last Name:BONNER
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 1:490 NW LOST SPRINGS TER STE 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6643
Mailing Address - Country:US
Mailing Address - Phone:949-836-1749
Mailing Address - Fax:
Practice Address - Street 1:3838 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1161
Practice Address - Country:US
Practice Address - Phone:503-206-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist