Healthcare Provider Details

I. General information

NPI: 1386971422
Provider Name (Legal Business Name): JESSELYN BOURQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N LAKE ST
MANISTIQUE MI
49854-1234
US

IV. Provider business mailing address

3865 S MACKINAC TRL
SAULT SAINTE MARIE MI
49783-9286
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-2144
  • Fax: 906-341-5793
Mailing address:
  • Phone: 906-632-2805
  • Fax: 906-632-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6803085678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: