Provider Demographics
NPI:1811216021
Name:BOUDREAU, JENNIFER BROOKE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BROOKE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BROOKE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:540 FORT EVANS RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-3379
Mailing Address - Country:US
Mailing Address - Phone:703-737-3500
Mailing Address - Fax:703-737-3550
Practice Address - Street 1:540 FORT EVANS RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3379
Practice Address - Country:US
Practice Address - Phone:703-737-3500
Practice Address - Fax:703-737-3550
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25438207Q00000X
VA0101258315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026353Medicaid
WV3810026353Medicaid
VAVV1253G155Medicare PIN
VAVVI253C275Medicare PIN