Basic Information
| Provider Information | |||||||||
| NPI: | 1114179108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULET | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOULET | ||||||||
| OtherFirstName: | NICK | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N HIGHLAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271014180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366078523 | ||||||||
| FaxNumber: | 3367271734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C008297 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1114179108 | 05 | NC | MEDICAID | 1114179108 | 01 | NC | HUMANA | OTHER | 1114179108 | 01 | NC | UBH | OTHER | MAGELLAN | 01 | NC | 601112-311 | OTHER | 18859 | 01 | NC | BCBS | OTHER |