Healthcare Provider Details

I. General information

NPI: 1609756469
Provider Name (Legal Business Name): JESSIE LYN BOUCHARD MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST HASBRO LOWER LEVEL
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-6195
  • Fax: 401-444-6378
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN04714
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberAPRN04714
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: