Provider Demographics
NPI:1316967334
Name:JACKSON-VERGARA, BONITA MARIE (LICENSED COUNSELOR)
Entity type:Individual
Prefix:DR
First Name:BONITA
Middle Name:MARIE
Last Name:JACKSON-VERGARA
Suffix:
Gender:F
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 FOX RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-6506
Mailing Address - Country:US
Mailing Address - Phone:704-804-9614
Mailing Address - Fax:757-312-9580
Practice Address - Street 1:1545 CROSSWAYS BLVD STE 250
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0218
Practice Address - Country:US
Practice Address - Phone:704-804-9614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000386101YA0400X
VA0701005902101YP2500X
NC4804101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103317Medicaid