Provider Demographics
NPI:1447508569
Name:BLANTON, BONNIE ANN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:ANN
Last Name:BLANTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NORTH WEST AVENUE
Mailing Address - Street 2:600
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N WEST AVE
Practice Address - Street 2:600
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2179
Practice Address - Country:US
Practice Address - Phone:517-780-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088175104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker