| NPI | 1679706113 |
|---|---|
| Former Name | JESSICA KATHLEEN BONATAKIS |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: PA PS018803) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: KY 129694) |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2021-06-21 |