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General NPI Number Information
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NPI Number | 1447295886
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Entity Type | Individual
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Provider Name | JACQUELINE D BOUTROUILLE M.D., P.A.
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Gender | Female
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Dates
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Enumeration Date | 06/19/2006
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Last Update Date | 01/11/2013
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Provider Practice Location Address
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Address Line | 7880 N UNIVERSITY DR SUITE 303
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City | TAMARAC
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State | FL
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Zip | 33321-2124
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Country | US
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Telephone | 954-340-3000
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Fax | 954-636-8407
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Provider Business Mailing Address
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Address Line | 7880 N UNIVERSITY DR SUITE 303
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City | TAMARAC
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State | FL
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Zip | 33321-2124
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Country | US
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Telephone | 954-340-3000
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Fax | 954-636-8407
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME 87029
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | ME 87029
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License Number State | FL
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