Provider Demographics
NPI:1508379413
Name:BOUCHER, JENNIFER ANN (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 TAYLOR PL
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-4313
Mailing Address - Country:US
Mailing Address - Phone:203-529-5123
Mailing Address - Fax:888-761-5161
Practice Address - Street 1:16 TAYLOR PL
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-4313
Practice Address - Country:US
Practice Address - Phone:203-529-5123
Practice Address - Fax:888-761-5161
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11727902103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst