Provider Demographics
NPI:1780146688
Name:BOUDREAU, JAMIE DAVID (ATC)
Entity type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:DAVID
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:114 HELEN DEARBORN RD
Mailing Address - Street 2:
Mailing Address - City:WEARE
Mailing Address - State:NH
Mailing Address - Zip Code:03281-5816
Mailing Address - Country:US
Mailing Address - Phone:603-437-5200
Mailing Address - Fax:603-437-5244
Practice Address - Street 1:19 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1208
Practice Address - Country:US
Practice Address - Phone:603-437-5200
Practice Address - Fax:603-437-5244
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH00722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer