Provider Demographics
NPI:1447295886
Name:BOUTROUILLE, JACQUELINE D (MD, PA)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:D
Last Name:BOUTROUILLE
Suffix:
Gender:F
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7880 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2124
Mailing Address - Country:US
Mailing Address - Phone:954-340-3000
Mailing Address - Fax:954-636-8407
Practice Address - Street 1:7880 N UNIVERSITY DR
Practice Address - Street 2:SUITE 303
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-2124
Practice Address - Country:US
Practice Address - Phone:954-340-3000
Practice Address - Fax:954-636-8407
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 870292084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268083100Medicaid
FL268083100Medicaid
FLK1643Medicare ID - Type Unspecified