Provider Demographics
NPI:1528669579
Name:BOUDREAU, JILLIAN ANNE (DPT)
Entity type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:ANNE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:JILLIAN
Other - Middle Name:ANNE
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:141 HAMPTON CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4103
Mailing Address - Country:US
Mailing Address - Phone:248-853-7555
Mailing Address - Fax:248-853-7556
Practice Address - Street 1:23965 NOVI RD STE 150
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-0203
Practice Address - Country:US
Practice Address - Phone:248-513-3730
Practice Address - Fax:248-513-3733
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist