Provider Demographics
NPI:1982701371
Name:BONNER, JO JAEGER (MD)
Entity Type:Individual
Prefix:MRS
First Name:JO
Middle Name:JAEGER
Last Name:BONNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12680 OLIVE BLVD.
Mailing Address - Street 2:STE. 200
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-8892
Mailing Address - Fax:314-251-8894
Practice Address - Street 1:12680 OLIVE BLVD.
Practice Address - Street 2:STE. 200
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-251-8892
Practice Address - Fax:314-251-8894
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36705174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO010567402Medicaid
MOE50723Medicare UPIN
MO260020Medicare ID - Type Unspecified