Healthcare Provider Details

I. General information

NPI: 1346597564
Provider Name (Legal Business Name): JASON EDWARD BONNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FULTON STREET
DURHAM NC
27705
US

IV. Provider business mailing address

508 FULTON STREET
DURHAM NC
27705
US

V. Phone/Fax

Practice location:
  • Phone: 919-286-0411
  • Fax:
Mailing address:
  • Phone: 919-286-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number4298
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: