Basic Information
| Provider Information | |||||||||
| NPI: | 1861098725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS-BONAM | ||||||||
| FirstName: | JAZZMIN | ||||||||
| MiddleName: | TONAI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43824 20TH ST W # 8878 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935345201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109517764 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12968 FREDERICK ST STE D | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512080150 | ||||||||
| FaxNumber: | 9512080409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2020 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 32243 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 32243 | 01 | CA | BOARD OF PSYCHOLOGY | OTHER |