Provider Demographics
NPI:1184193369
Name:BOUCIQUOT, JEAN-MICHAEL (LMFT)
Entity Type:Individual
Prefix:
First Name:JEAN-MICHAEL
Middle Name:
Last Name:BOUCIQUOT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11288 SW 9TH CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4304
Mailing Address - Country:US
Mailing Address - Phone:305-934-8832
Mailing Address - Fax:
Practice Address - Street 1:11011 SHERIDAN ST STE 211
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1531
Practice Address - Country:US
Practice Address - Phone:305-934-8832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist