Healthcare Provider Details

I. General information

NPI: 1063300713
Provider Name (Legal Business Name): JACQUELINE BOURRIAGUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE OTTOSEN

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 US HIGHWAY 93 S
KALISPELL MT
59901-8499
US

IV. Provider business mailing address

608 MOUNTAIN VIEW DR
KALISPELL MT
59901-6699
US

V. Phone/Fax

Practice location:
  • Phone: 406-890-2570
  • Fax:
Mailing address:
  • Phone: 425-772-8376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberBBH-PCLC-LIC-79732
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: