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General NPI Number Information
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NPI Number | 1366176083
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Entity Type | Individual
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Provider Name | JENNA WOODALL BOURGEOIS
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Gender | Female
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Dates
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Enumeration Date | 07/11/2022
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Last Update Date | 07/11/2022
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Provider Practice Location Address
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Address Line | 124 MAIN ST # 2
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City | DEEP RIVER
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State | CT
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Zip | 06417-1756
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Country | US
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Telephone | 860-526-1756
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Fax |
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Provider Business Mailing Address
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Address Line | 156 WILLOW ST APT 1
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City | NEW HAVEN
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State | CT
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Zip | 06511-2673
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Country | US
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Telephone | 203-249-1361
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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 | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 12.010268
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License Number State | CT
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