Provider Demographics
NPI:1609873637
Name:BOURDET, JAMES M (PT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:M
Last Name:BOURDET
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 RIDGEWOOD RD SE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OR
Mailing Address - Zip Code:97352-9217
Mailing Address - Country:US
Mailing Address - Phone:541-327-3674
Mailing Address - Fax:
Practice Address - Street 1:1270 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4113
Practice Address - Country:US
Practice Address - Phone:503-581-7232
Practice Address - Fax:503-581-6511
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0521225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR237107Medicaid
OR139710Medicare PIN