Provider Demographics
NPI:1013062405
Name:BOUTWELL, JACQUE ARLIN JR (CFA)
Entity Type:Individual
Prefix:MR
First Name:JACQUE
Middle Name:ARLIN
Last Name:BOUTWELL
Suffix:JR
Gender:M
Credentials:CFA
Other - Prefix:
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Mailing Address - Street 1:5146 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:574-214-7504
Mailing Address - Fax:574-262-3214
Practice Address - Street 1:3301 COUNTY RD 6 E
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-7673
Practice Address - Country:US
Practice Address - Phone:574-214-7504
Practice Address - Fax:574-262-3214
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2014-11-25
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000577411OtherANTHEM BCBS