Basic Information
| Provider Information | |||||||||
| NPI: | 1215310669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940628 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LIBERTY ST STE 2A | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940766 | ||||||||
| FaxNumber: | 5085650097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2015 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI 60543717 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.