Basic Information
| Provider Information | |||||||||
| NPI: | 1033456595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTIN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCLAM | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 NEW STATE HWY | ||||||||
| Address2: | |||||||||
| City: | RAYNHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027675460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806868 | ||||||||
| FaxNumber: | 5088806848 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 NEW STATE HWY | ||||||||
| Address2: | |||||||||
| City: | RAYNHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027675460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806868 | ||||||||
| FaxNumber: | 5088806848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2013 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.