Basic Information
| Provider Information | |||||||||
| NPI: | 1033724299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONACK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | BA, MDIV | ||||||||
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| Mailing Information | |||||||||
| Address1: | W175N11120 STONEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530224799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Practice Location | |||||||||
| Address1: | 2669 N RICHARDS ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532122850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004381772 | ||||||||
| FaxNumber: | 2623455562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2020 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 5121-226 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.