Provider Demographics
NPI:1942697198
Name:JORDAN BOUCHER
Entity Type:Organization
Organization Name:JORDAN BOUCHER
Other - Org Name:LIVELY GREENS
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:713-689-9673
Mailing Address - Street 1:3333 SE HORSTMAN RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4054
Mailing Address - Country:US
Mailing Address - Phone:713-689-9673
Mailing Address - Fax:
Practice Address - Street 1:3333 SE HORSTMAN RD
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4054
Practice Address - Country:US
Practice Address - Phone:713-689-9673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60543717133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty