Healthcare Provider Details

I. General information

NPI: 1295890606
Provider Name (Legal Business Name): MARILYN JEANNE BONJEAN ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/11/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 N FARWELL AVE
MILWAUKEE WI
53202-2329
US

IV. Provider business mailing address

3920 N DOWNER AVE
SHOREWOOD WI
53211-2466
US

V. Phone/Fax

Practice location:
  • Phone: 414-273-2220
  • Fax: 414-273-2223
Mailing address:
  • Phone: 414-964-7493
  • Fax: 414-273-2223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8-124
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number8-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: