Provider Demographics
NPI:1477395390
Name:BONVILLE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BONVILLE
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 1:251 N MAIN STREET
Mailing Address - Street 2:ATHLETIC TRAINING
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314-9998
Mailing Address - Country:US
Mailing Address - Phone:207-551-7281
Mailing Address - Fax:
Practice Address - Street 1:251 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-8501
Practice Address - Country:US
Practice Address - Phone:937-766-7905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer