Provider Demographics
NPI:1811294127
Name:BOUDREAU, JENNIFER LYNN (MOTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:6520 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-5703
Mailing Address - Country:US
Mailing Address - Phone:321-622-8792
Mailing Address - Fax:
Practice Address - Street 1:6520 3RD ST
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5703
Practice Address - Country:US
Practice Address - Phone:321-622-8792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14026225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics