Healthcare Provider Details

I. General information

NPI: 1518219302
Provider Name (Legal Business Name): JENNIFER H. BOURGOIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER TRACEY HAWORTH PSY.D.

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 EXCHANGE ST SUITE 403
PORTLAND ME
04101
US

IV. Provider business mailing address

57 EXCHANGE ST SUITE 403
PORTLAND ME
04101
US

V. Phone/Fax

Practice location:
  • Phone: 617-431-4608
  • Fax:
Mailing address:
  • Phone: 617-431-4608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10275
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS1620
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number10275
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number024452
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number10275
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: