Provider Demographics
NPI:1427542588
Name:BOUCHARD, JENNIFER (LPTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 GATEWAY DR SE APT 922
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4042
Mailing Address - Country:US
Mailing Address - Phone:703-909-7707
Mailing Address - Fax:
Practice Address - Street 1:13650 HEATHCOTE BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3344
Practice Address - Country:US
Practice Address - Phone:571-284-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603592225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant