Healthcare Provider Details

I. General information

NPI: 1649107574
Provider Name (Legal Business Name): JASON BONILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 HUNTER POINT RD
POMONA CA
91766-4959
US

IV. Provider business mailing address

39 HUNTER POINT RD
POMONA CA
91766-4959
US

V. Phone/Fax

Practice location:
  • Phone: 909-670-6416
  • Fax:
Mailing address:
  • Phone: 909-670-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number21249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: