Provider Demographics
NPI:1063023265
Name:BOUGES, JESSICA KAYE
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:KAYE
Last Name:BOUGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 E BRIGHTON AVE APT 802
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2508
Mailing Address - Country:US
Mailing Address - Phone:315-396-2847
Mailing Address - Fax:
Practice Address - Street 1:821 E BRIGHTON AVE APT 802
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2508
Practice Address - Country:US
Practice Address - Phone:315-396-2847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0482441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty