Healthcare Provider Details

I. General information

NPI: 1235073552
Provider Name (Legal Business Name): JEFFREY BOURG AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 SHIRLEY PL
BEVERLY HILLS CA
90212-4177
US

IV. Provider business mailing address

407 SHIRLEY PL
BEVERLY HILLS CA
90212-4177
US

V. Phone/Fax

Practice location:
  • Phone: 310-490-7389
  • Fax:
Mailing address:
  • Phone: 310-490-7389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number149966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: