Provider Demographics
NPI:1053128389
Name:JANTZEN, BONNIE E
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:E
Last Name:JANTZEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKFIELD GLEN DR
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:NJ
Mailing Address - Zip Code:07823-2854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKFIELD GLEN DR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:NJ
Practice Address - Zip Code:07823-2854
Practice Address - Country:US
Practice Address - Phone:908-652-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00841700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist