Provider Demographics
NPI:1073871844
Name:BOUCHARD, JACQUES MAURICE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:MAURICE
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:623 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3042
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine