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General NPI Number Information
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NPI Number | 1427542588
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Entity Type | Individual
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Provider Name | JENNIFER BOUCHARD LPTA
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Gender | Female
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Dates
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Enumeration Date | 06/21/2018
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 13650 HEATHCOTE BLVD
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City | GAINESVILLE
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State | VA
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Zip | 20155-3344
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Country | US
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Telephone | 571-284-7244
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Fax |
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Provider Business Mailing Address
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Address Line | 775 GATEWAY DR SE APT 922
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City | LEESBURG
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State | VA
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Zip | 20175-4042
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Country | US
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Telephone | 703-909-7707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2306603592
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License Number State | VA
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