Healthcare Provider Details

I. General information

NPI: 1164295754
Provider Name (Legal Business Name): JENNIFER M L BONI MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5465 MERCHANT CIR STE 1
PLACERVILLE CA
95667-9711
US

IV. Provider business mailing address

2001 GOLDORADO TRL
EL DORADO CA
95623-4521
US

V. Phone/Fax

Practice location:
  • Phone: 530-929-7493
  • Fax:
Mailing address:
  • Phone: 612-600-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER MADELINE LEE BONI
Title or Position: CEO
Credential: MD
Phone: 612-600-5366