Provider Demographics
NPI:1669786653
Name:BONNETT, JESSICA E (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:BONNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-883-2224
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:623 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2983
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1262207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program