Basic Information
| Provider Information | |||||||||
| NPI: | 1134754336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURDON | ||||||||
| FirstName: | JACQUELYNN | ||||||||
| MiddleName: | RENAE | ||||||||
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| OtherLastName: | BOURDON | ||||||||
| OtherFirstName: | JAX | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 32100 TELEGRAPH RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480252454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487124266 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 32100 TELEGRAPH RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480252454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487124266 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2020 | ||||||||
| LastUpdateDate: | 03/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | MI | Y | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.