Provider Demographics
NPI:1952722795
Name:BOULWARE, JENNIFER (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:M
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 FAIRWAY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1834
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:780 LYNNHAVEN PKWY STE 400
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7332
Practice Address - Country:US
Practice Address - Phone:602-478-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ77162355S0801X
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant