Provider Demographics
NPI:1578073557
Name:BOUTIN, JESSICA (MSOTR/L, WCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MSOTR/L, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 THURLOW ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01833-1132
Mailing Address - Country:US
Mailing Address - Phone:978-430-5367
Mailing Address - Fax:
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5568
Practice Address - Country:US
Practice Address - Phone:774-826-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA332720225X00000X
NH2433225X00000X
MA11366225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist