Provider Demographics
NPI:1073871844
Name:BOUCHARD, JACQUES MAURICE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:MAURICE
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S ALMON ST APT A
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2986
Mailing Address - Country:US
Mailing Address - Phone:208-550-3060
Mailing Address - Fax:208-210-1640
Practice Address - Street 1:515 S ALMON ST APT A
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2986
Practice Address - Country:US
Practice Address - Phone:208-550-3060
Practice Address - Fax:208-210-1640
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine