Provider Demographics
NPI:1174223358
Name:BOULDIN, JESSICA BRUNOT (CLC, CD)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BRUNOT
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:CLC, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 APACHE TRAIL
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-1300
Mailing Address - Country:US
Mailing Address - Phone:540-222-8700
Mailing Address - Fax:
Practice Address - Street 1:102 APACHE TRAIL
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-1300
Practice Address - Country:US
Practice Address - Phone:540-222-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
VA351584174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA81180Medicaid