Provider Demographics
NPI:1295890606
Name:BONJEAN, MARILYN JEANNE (EDD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:JEANNE
Last Name:BONJEAN
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 N DOWNER AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2466
Mailing Address - Country:US
Mailing Address - Phone:414-964-7493
Mailing Address - Fax:414-273-2223
Practice Address - Street 1:1524 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2329
Practice Address - Country:US
Practice Address - Phone:414-273-2220
Practice Address - Fax:414-273-2223
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8-124106H00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39242000Medicaid