Provider Demographics
NPI:1750602496
Name:BOULAIS, JACLYN (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BOULAIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 SOUTH ST
Mailing Address - Street 2:UNIT 6A
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3958
Mailing Address - Country:US
Mailing Address - Phone:413-281-3814
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253867208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics