Provider Demographics
NPI:1699209320
Name:BOURQUE, JENNIFER LYNNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:BOURQUE
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 1:10252 SE US HIGHWAY 441
Mailing Address - Street 2:UNIT 3 & 4
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-6819
Mailing Address - Country:US
Mailing Address - Phone:352-559-2539
Mailing Address - Fax:352-547-5787
Practice Address - Street 1:10252 SE US HIGHWAY 441
Practice Address - Street 2:UNIT 3 & 4
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-6819
Practice Address - Country:US
Practice Address - Phone:352-559-2539
Practice Address - Fax:352-547-5787
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician