Provider Demographics
NPI:1861098725
Name:HICKS-BONAM, JAZZMIN TONAI (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAZZMIN
Middle Name:TONAI
Last Name:HICKS-BONAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43824 20TH ST W # 8878
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-5201
Mailing Address - Country:US
Mailing Address - Phone:310-951-7764
Mailing Address - Fax:
Practice Address - Street 1:12968 FREDERICK ST STE D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5229
Practice Address - Country:US
Practice Address - Phone:951-208-0150
Practice Address - Fax:951-208-0409
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32243OtherBOARD OF PSYCHOLOGY