Provider Demographics
NPI:1396801874
Name:BOUCHE, JEAN (RD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:BOUCHE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SHORE DR
Mailing Address - Street 2:DIETARY
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4242
Mailing Address - Country:US
Mailing Address - Phone:715-735-4200
Mailing Address - Fax:715-735-8017
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:DIETARY
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-4242
Practice Address - Country:US
Practice Address - Phone:715-735-4200
Practice Address - Fax:715-735-8017
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1276-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered