Provider Demographics
NPI:1710005608
Name:BOURBONNAIS, JENNIFER (MED, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOURBONNAIS
Suffix:
Gender:F
Credentials:MED, RD, LDN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED RD
Mailing Address - Street 1:9800 MOODY CT
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-6643
Mailing Address - Country:US
Mailing Address - Phone:248-909-8555
Mailing Address - Fax:
Practice Address - Street 1:9800 MOODY CT
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-6643
Practice Address - Country:US
Practice Address - Phone:248-909-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI864114133V00000X
NCL005862133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N62900Medicare ID - Type UnspecifiedMEDICARE