Provider Demographics
NPI:1992938377
Name:BOUCHARD, JODY (RN)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 BOLGOS CIR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1564
Mailing Address - Country:US
Mailing Address - Phone:734-615-3267
Mailing Address - Fax:734-615-4674
Practice Address - Street 1:3156 BOLGOS CIR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1564
Practice Address - Country:US
Practice Address - Phone:734-615-3267
Practice Address - Fax:734-615-4674
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704088310163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse