Provider Demographics
NPI:1528685542
Name:BOUCHILLON, MARY JENNINGS (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JENNINGS
Last Name:BOUCHILLON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8205 PRESIDENTS DR
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-8621
Mailing Address - Country:US
Mailing Address - Phone:717-839-2188
Mailing Address - Fax:717-565-1104
Practice Address - Street 1:2319 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-9199
Practice Address - Country:US
Practice Address - Phone:662-869-9980
Practice Address - Fax:662-869-9970
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist