Provider Demographics
NPI:1376932285
Name:BOUCHARD, JESSICA (RD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 S GAYLORD CT APT C505
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3195
Mailing Address - Country:US
Mailing Address - Phone:207-991-2086
Mailing Address - Fax:
Practice Address - Street 1:2855 N SPEER BLVD STE B
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-4240
Practice Address - Country:US
Practice Address - Phone:720-295-4515
Practice Address - Fax:855-710-2814
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1234133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered