Provider Demographics
NPI:1518219302
Name:BOURGOIN, JENNIFER H (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:H
Last Name:BOURGOIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:TRACEY
Other - Last Name:HAWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:57 EXCHANGE ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101
Mailing Address - Country:US
Mailing Address - Phone:617-431-4608
Mailing Address - Fax:
Practice Address - Street 1:57 EXCHANGE ST
Practice Address - Street 2:SUITE 403
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:617-431-4608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1620103T00000X
MA10275103T00000X, 103TC0700X, 101YM0800X
NY024452103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical