Provider Demographics
NPI:1942939111
Name:BONNER, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20829 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-2318
Mailing Address - Country:US
Mailing Address - Phone:440-840-6200
Mailing Address - Fax:
Practice Address - Street 1:3100 E 45TH ST STE 116
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1094
Practice Address - Country:US
Practice Address - Phone:216-526-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 374U00000X
OH251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide