Healthcare Provider Details

I. General information

NPI: 1861397036
Provider Name (Legal Business Name): JESSICA BOUCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 EDDIE DOWLING HWY
NORTH SMITHFIELD RI
02896-7337
US

IV. Provider business mailing address

2220 PLAINFIELD PIKE
CRANSTON RI
02921-2031
US

V. Phone/Fax

Practice location:
  • Phone: 401-889-3780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC02135
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: