Provider Demographics
NPI:1609037423
Name:BONNER, JANICE KATHRYN (LCSW)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:KATHRYN
Last Name:BONNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:KATHRYN
Other - Last Name:BLAZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:2560 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-4118
Practice Address - Country:US
Practice Address - Phone:870-972-4000
Practice Address - Fax:870-892-0930
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2506-C1041C0700X
AR104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227215719Medicaid