Provider Demographics
NPI:1447210836
Name:BOULTER, JAY L (LMFT, LPC)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:L
Last Name:BOULTER
Suffix:
Gender:M
Credentials:LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-9111
Mailing Address - Country:US
Mailing Address - Phone:704-633-3117
Mailing Address - Fax:704-633-3117
Practice Address - Street 1:203 CEDARWOOD DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-9111
Practice Address - Country:US
Practice Address - Phone:704-633-3117
Practice Address - Fax:704-633-3117
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2335101YP2500X
NC489106H00000X
CAMFC 19316106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34918OtherCIGNA BEHAVIORAL PIN
NC1010UOtherBCBSNC PIN
NC5746163OtherAETNA PIN
NC118421OtherVALUE OPTIONS PIN
NC1584Medicaid