Provider Demographics
NPI:1457869307
Name:BONAR, JAIME RACHELLE MORTIMER (OTR/L, RBT)
Entity Type:Individual
Prefix:
First Name:JAIME RACHELLE
Middle Name:MORTIMER
Last Name:BONAR
Suffix:
Gender:F
Credentials:OTR/L, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7217 RAYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-6648
Mailing Address - Country:US
Mailing Address - Phone:816-863-9964
Mailing Address - Fax:
Practice Address - Street 1:1300 LOCUST ST STE C
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1366
Practice Address - Country:US
Practice Address - Phone:417-448-9766
Practice Address - Fax:816-265-1828
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020006444225X00000X
MORBT-16-15377106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician