Provider Demographics
NPI:1396815692
Name:BOISVERT, JACQUELINE A (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:A
Last Name:BOISVERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-2121
Mailing Address - Country:US
Mailing Address - Phone:401-886-4349
Mailing Address - Fax:
Practice Address - Street 1:74 FRENCHTOWN RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-1758
Practice Address - Country:US
Practice Address - Phone:401-862-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00519152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9007984Medicaid
RI9007984Medicaid