Provider Demographics
NPI:1952762924
Name:BONANNO, JEANINE PATRICE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:PATRICE
Last Name:BONANNO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16224 JAMAICA AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4910
Mailing Address - Country:US
Mailing Address - Phone:718-657-2021
Mailing Address - Fax:
Practice Address - Street 1:16224 JAMAICA AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4910
Practice Address - Country:US
Practice Address - Phone:718-657-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0752611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY80Medicaid