Provider Demographics
NPI:1225329360
Name:BOUCHER-STEWART, JACQUELINE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:BOUCHER-STEWART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1220 E ELM ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2850
Mailing Address - Country:US
Mailing Address - Phone:419-224-5437
Mailing Address - Fax:
Practice Address - Street 1:1220 E ELM ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2850
Practice Address - Country:US
Practice Address - Phone:419-224-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-24
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant