Healthcare Provider Details

I. General information

NPI: 1598606238
Provider Name (Legal Business Name): JILL BOURGET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 CALLE LEE
LOS ALAMITOS CA
90720-2544
US

IV. Provider business mailing address

10601 CALLE LEE STE 179
LOS ALAMITOS CA
90720-6785
US

V. Phone/Fax

Practice location:
  • Phone: 818-575-6800
  • Fax:
Mailing address:
  • Phone: 831-582-1017
  • Fax: 818-575-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: