Provider Demographics
NPI:1437540879
Name:BOURGEOIS, JILL (HIS)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LAKE ST
Mailing Address - Street 2:PO BOX 128
Mailing Address - City:COTUIT
Mailing Address - State:MA
Mailing Address - Zip Code:02635-3013
Mailing Address - Country:US
Mailing Address - Phone:508-681-5769
Mailing Address - Fax:
Practice Address - Street 1:156 CHURCH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-2045
Practice Address - Country:US
Practice Address - Phone:781-826-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist