Basic Information
| Provider Information | |||||||||
| NPI: | 1578823662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURBONNAIS | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8459 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972078459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18980 LELAND RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970458511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2012 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 372600000X | Y | Nursing Service Related Providers | Adult Companion |
No ID Information.