Basic Information
| Provider Information | |||||||||
| NPI: | 1669786653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNETT | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838433046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088824511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 W A ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | MOSCOW | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838436000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088822011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2010 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | O-1262 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.