Provider Demographics
NPI:1437637873
Name:BOUCHARD-HALL, JENNIFER NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:BOUCHARD-HALL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 KEENEY RD
Mailing Address - Street 2:
Mailing Address - City:FABIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13063-9790
Mailing Address - Country:US
Mailing Address - Phone:915-503-3577
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2730
Practice Address - Country:US
Practice Address - Phone:315-435-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker