Basic Information
| Provider Information | |||||||||
| NPI: | 1710593967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONILLA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | N/A | ||||||||
| OtherFirstName: | N/A | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6149 | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970070149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033528657 | ||||||||
| FaxNumber: | 5033528658 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971234157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035974500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 202008134NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.