Provider Demographics
NPI:1295058402
Name:BONNER, JENNIFER CANDACE (MS)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:CANDACE
Last Name:BONNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 FALLING MOSS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8583
Mailing Address - Country:US
Mailing Address - Phone:843-566-2570
Mailing Address - Fax:
Practice Address - Street 1:107 W 5TH NORTH ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6446
Practice Address - Country:US
Practice Address - Phone:843-871-9669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3922231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3922OtherSC STATE LICENSE
SC3922OtherSC STATE LICENSE