MEDICARE: JACQUELINE BOUTROS MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	000119920	MA
2	1041C0700X	Clinical Social Worker	57000	TX

General Provider Information

NPI Number	:	1407395767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE BOUTROS MSW, LCSW

Provider Business Mailing Address
First Line	:	1430 COLLIER ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-2911
Country	:	US
Telephone Number	:	512-445-7787
Fax Number	:	512-440-4059

Provider Business Practice Location Address
First Line	:	4920 N INTERSTATE 35
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-2716
Country	:	US
Telephone Number	:	512-472-4357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2017
Last Update Date	:	03/07/2018

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