Provider Demographics
NPI:1982719431
Name:BOUGHAN, JERRI ANNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRI
Middle Name:ANNE
Last Name:BOUGHAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-2089
Mailing Address - Country:US
Mailing Address - Phone:618-943-5664
Mailing Address - Fax:618-943-4037
Practice Address - Street 1:2300 JAMES ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-2089
Practice Address - Country:US
Practice Address - Phone:618-943-5664
Practice Address - Fax:618-943-4037
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist