Healthcare Provider Details

I. General information

NPI: 1114207040
Provider Name (Legal Business Name): JENNIFER LYNN BOURGEOIS MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 HOPKINS RD
NEW BOSTON NH
03070-4416
US

IV. Provider business mailing address

27 HOPKINS RD
NEW BOSTON NH
03070-4416
US

V. Phone/Fax

Practice location:
  • Phone: 603-487-3955
  • Fax:
Mailing address:
  • Phone: 603-487-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number916
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: