Provider Demographics
NPI:1912917451
Name:BONANNO, JAMIE L
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:BONANNO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GREEN HILL RD
Mailing Address - Street 2:
Mailing Address - City:PARKESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:19365-9173
Mailing Address - Country:US
Mailing Address - Phone:610-384-7711
Mailing Address - Fax:610-466-2243
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:610-384-7711
Practice Address - Fax:610-466-2243
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health