Provider Demographics
NPI:1366176083
Name:BOURGEOIS, JENNA WOODALL
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:WOODALL
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 WILLOW ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2673
Mailing Address - Country:US
Mailing Address - Phone:203-249-1361
Mailing Address - Fax:
Practice Address - Street 1:124 MAIN ST # 2
Practice Address - Street 2:
Practice Address - City:DEEP RIVER
Practice Address - State:CT
Practice Address - Zip Code:06417-1756
Practice Address - Country:US
Practice Address - Phone:860-526-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.010268363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health