MEDICARE: MRS. JENNA ROSE BONACCORSO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	OS22105	FL

General Provider Information

NPI Number	:	1063973733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNA ROSE BONACCORSO DO

Provider Business Mailing Address
First Line	:	770 W GRANADA BLVD STE 101
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5179
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5821 S WILLIAMSON BLVD STE 201
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-6102
Country	:	US
Telephone Number	:	386-231-3420
Fax Number	:	386-231-3499

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	08/26/2025

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