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General NPI Number Information
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NPI Number | 1275936718
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Entity Type | Individual
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Provider Name | JESSICA BOURQUE PT
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Gender | Female
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Dates
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Enumeration Date | 09/29/2014
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Last Update Date | 09/29/2014
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Provider Practice Location Address
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Address Line | 147 HIGH ST
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City | MEDFIELD
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State | MA
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Zip | 02052-3116
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Country | US
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Telephone | 617-640-7275
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Fax |
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Provider Business Mailing Address
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Address Line | 147 HIGH ST
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City | MEDFIELD
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State | MA
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Zip | 02052-3116
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Country | US
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Telephone | 617-640-7275
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 8777 PT
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License Number State | MA
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