Provider Demographics
NPI:1376721779
Name:BOURASSA, JERRY JOSEPH (PHYSICAL THERAPSIT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:JOSEPH
Last Name:BOURASSA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 S GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4710
Mailing Address - Country:US
Mailing Address - Phone:928-717-3236
Mailing Address - Fax:
Practice Address - Street 1:146 S GRANITE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4710
Practice Address - Country:US
Practice Address - Phone:928-717-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1370174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist