Provider Demographics
NPI:1932429701
Name:BONNEAU, JERRY W (LAC, AAS)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:BONNEAU
Suffix:
Gender:M
Credentials:LAC, AAS
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 7115
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59904-0115
Mailing Address - Country:US
Mailing Address - Phone:406-756-6453
Mailing Address - Fax:
Practice Address - Street 1:1312 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3095
Practice Address - Country:US
Practice Address - Phone:406-756-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1298101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)