Provider Demographics
NPI:1184804577
Name:JENNIFER C BOURST DC PA
Entity type:Organization
Organization Name:JENNIFER C BOURST DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOURST
Authorized Official - Suffix:
Authorized Official - Credentials:DC PA
Authorized Official - Phone:407-654-4506
Mailing Address - Street 1:13750 W COLONIAL DR
Mailing Address - Street 2:SUITE 318
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4204
Mailing Address - Country:US
Mailing Address - Phone:407-654-4506
Mailing Address - Fax:407-654-4506
Practice Address - Street 1:13750 W COLONIAL DR
Practice Address - Street 2:SUITE 318
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4204
Practice Address - Country:US
Practice Address - Phone:407-654-4506
Practice Address - Fax:407-654-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 7986111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8143OtherGROUP IDENTIFICATION NUMB
FLK8143OtherGROUP IDENTIFICATION NUMB