Provider Demographics
NPI:1346674504
Name:BOUTIN, JENNIFER MICHELLE (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 LUCERNE TER
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1013
Mailing Address - Country:US
Mailing Address - Phone:407-894-1444
Mailing Address - Fax:407-894-3599
Practice Address - Street 1:918 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1013
Practice Address - Country:US
Practice Address - Phone:407-894-1444
Practice Address - Fax:407-894-3599
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5204133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered