Basic Information
| Provider Information | |||||||||
| NPI: | 1467646117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUGIE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 CRITTENDEN BLVD APT 238 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038177098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5130 EAST MAIN STREET ROAD, SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140203496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853441421 | ||||||||
| FaxNumber: | 5853443047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 09/07/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.