Basic Information
| Provider Information | |||||||||
| NPI: | 1386286235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOURGEOIS | ||||||||
| FirstName: | JAYME | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9932 SWEET BASIL DR | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275874127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327705706 | ||||||||
| FaxNumber: | 9198829502 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 NORMANDY RD | ||||||||
| Address2: | |||||||||
| City: | LOUISBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275499032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194952543 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2019 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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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 | 224Z00000X | 5022 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.