Provider Demographics
NPI:1962191304
Name:BOUROULT, JEANETTE FOX (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:FOX
Last Name:BOUROULT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 KING HILL CT
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-3409
Mailing Address - Country:US
Mailing Address - Phone:860-916-5135
Mailing Address - Fax:
Practice Address - Street 1:217 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3602
Practice Address - Country:US
Practice Address - Phone:973-983-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00711500103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist