Provider Demographics
NPI:1386493583
Name:BOURDON, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:BOURDON
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:PO BOX 635242
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-5242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1382 BLUE OAKS BLVD STE 213
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7052
Practice Address - Country:US
Practice Address - Phone:877-412-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139704106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist