Healthcare Provider Details

I. General information

NPI: 1760733372
Provider Name (Legal Business Name): JACALYN CORRINE BOUCHER CLINICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 COMMERCIAL ST SUITE 200
WORCESTER MA
01608-1726
US

IV. Provider business mailing address

76 SUMMER ST STE 135A
FITCHBURG MA
01420-5783
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-4665
  • Fax: 508-752-0947
Mailing address:
  • Phone: 978-870-9905
  • Fax: 978-268-5768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: