Healthcare Provider Details

I. General information

NPI: 1477468528
Provider Name (Legal Business Name): JENNIFER BONINO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 VIA ALTA MESA
NIPOMO CA
93444-9344
US

IV. Provider business mailing address

1661 VIA ALTA MESA
NIPOMO CA
93444-9344
US

V. Phone/Fax

Practice location:
  • Phone: 805-474-3670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number38307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: