Provider Demographics
NPI:1639937154
Name:BOULRIS, JACQUELINE ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNE
Last Name:BOULRIS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:BOULRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1860 TOWN CENTER DR STE 240
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5899
Mailing Address - Country:US
Mailing Address - Phone:703-796-1986
Mailing Address - Fax:
Practice Address - Street 1:1860 TOWN CENTER DR STE 240
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5899
Practice Address - Country:US
Practice Address - Phone:703-796-1986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical