Provider Demographics
NPI:1245672500
Name:BOUGARD -JORDAN, KELLIE
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:
Last Name:BOUGARD -JORDAN
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 2843
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0095
Mailing Address - Country:US
Mailing Address - Phone:714-480-6692
Mailing Address - Fax:
Practice Address - Street 1:401 W CIVIC CENTER DR STE 600
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4515
Practice Address - Country:US
Practice Address - Phone:714-480-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC7815101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional