Provider Demographics
NPI:1588853063
Name:BOUCHER, JASON ANDREW (LMFT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2018
Mailing Address - Country:US
Mailing Address - Phone:860-450-0585
Mailing Address - Fax:860-450-0763
Practice Address - Street 1:40 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2018
Practice Address - Country:US
Practice Address - Phone:860-450-0585
Practice Address - Fax:860-450-0763
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001475106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist