Provider Demographics
NPI:1740565753
Name:BOURSIQUOT, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BOURSIQUOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 E 85TH ST
Mailing Address - Street 2:2ND FL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3804
Mailing Address - Country:US
Mailing Address - Phone:347-774-5565
Mailing Address - Fax:
Practice Address - Street 1:460 W 34TH ST
Practice Address - Street 2:9TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:212-273-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304818164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse