Provider Demographics
NPI:1063300713
Name:BOURRIAGUE, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOURRIAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:OTTOSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:608 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6699
Mailing Address - Country:US
Mailing Address - Phone:425-772-8376
Mailing Address - Fax:
Practice Address - Street 1:2282 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-8499
Practice Address - Country:US
Practice Address - Phone:406-890-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-79732101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional