Healthcare Provider Details

I. General information

NPI: 1528669579
Provider Name (Legal Business Name): JILLIAN ANNE BOUDREAU DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN ANNE ODOM DPT

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23965 NOVI RD STE 150
NOVI MI
48375-0203
US

IV. Provider business mailing address

141 HAMPTON CIR
ROCHESTER HILLS MI
48307-4103
US

V. Phone/Fax

Practice location:
  • Phone: 248-513-3730
  • Fax: 248-513-3733
Mailing address:
  • Phone: 248-853-7555
  • Fax: 248-853-7556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019850
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: