Healthcare Provider Details

I. General information

NPI: 1780146688
Provider Name (Legal Business Name): JAMIE DAVID BOUDREAU ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 N MAIN ST
DERRY NH
03038-1208
US

IV. Provider business mailing address

114 HELEN DEARBORN RD
WEARE NH
03281-5816
US

V. Phone/Fax

Practice location:
  • Phone: 603-437-5200
  • Fax: 603-437-5244
Mailing address:
  • Phone: 603-437-5200
  • Fax: 603-437-5244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0072
License Number StateNH

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: