Provider Demographics
NPI:1740274745
Name:BOULET, JEFFERSON L (PAC)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:L
Last Name:BOULET
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:BUCKLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98321-1268
Mailing Address - Country:US
Mailing Address - Phone:360-829-0625
Mailing Address - Fax:360-829-9860
Practice Address - Street 1:305 N RIVER AVE
Practice Address - Street 2:
Practice Address - City:BUCKLEY
Practice Address - State:WA
Practice Address - Zip Code:98321-8978
Practice Address - Country:US
Practice Address - Phone:360-829-0625
Practice Address - Fax:360-829-9860
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003567363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8542300Medicaid
WA8542300Medicaid
WA8542300Medicaid
WAMB0292160OtherDEA