Provider Demographics
NPI:1124855408
Name:BOURDETTE, JENNIFER K
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:BOURDETTE
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 1:661 JUDSON STREET RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3944
Mailing Address - Country:US
Mailing Address - Phone:315-244-0451
Mailing Address - Fax:
Practice Address - Street 1:22 STATE HIGHWAY 310
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1459
Practice Address - Country:US
Practice Address - Phone:315-386-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker