Provider Demographics
NPI:1588994800
Name:BOUCHER, JANNIFER L (LPC)
Entity type:Individual
Prefix:
First Name:JANNIFER
Middle Name:L
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 19TH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-2502
Mailing Address - Country:US
Mailing Address - Phone:620-792-5700
Mailing Address - Fax:620-792-5742
Practice Address - Street 1:1905 19TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-2502
Practice Address - Country:US
Practice Address - Phone:620-792-5700
Practice Address - Fax:620-792-5742
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCAC 107101YA0400X
KSLPC 864101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)