Provider Demographics
NPI:1801908363
Name:BONILLA, JORGE SR
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:BONILLA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 ARGYLE LN S
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5108
Mailing Address - Country:US
Mailing Address - Phone:217-828-0033
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2345
Practice Address - Country:US
Practice Address - Phone:815-928-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health