Jacqueline Anne Boulris, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

0110009803 Issued in VA

Practice address

1860 Town Center Dr Ste 240
Reston, VA 20190-5899

Phone

(703) 796-1986

NPI assigned

Mar 11, 2024

Last updated

Feb 21, 2025By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Jackie Boulris Other name

Medicare fee-for-service enrollment

Enrolled in DC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2023

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Privia Medical Group, LLC

  • Internal Medicine Physician
  • Arlington, VA
  • NPI 1013042480

  DC

  Medicare reassignment

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1710115200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1740096000000",
    "number": "1639937154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1860 TOWN CENTER DR STE 240",
            "city": "RESTON",
            "state": "VA",
            "postal_code": "201905899",
            "telephone_number": "703-796-1986"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1860 TOWN CENTER DR STE 240",
            "city": "RESTON",
            "state": "VA",
            "postal_code": "201905899",
            "telephone_number": "703-796-1986"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOULRIS",
        "first_name": "JACQUELINE",
        "middle_name": "ANNE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-03-11",
        "last_updated": "2025-02-21",
        "certification_date": "2025-02-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "VA",
            "license": "0110009803",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACKIE",
            "last_name": "BOULRIS",
            "credential": "PA-C",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Mary Bonvissuto, APRN
• Elda A Bordon, DDS, MPH
• Kristopher Bosque
• Macy Reed Bosshard, PA-C
• Hayley Boucher, DPT
• Charbel Bousraih
• Katherine Anne Hartman Bowen, MSW, LCSW
• Michael G Bowers, DO
• Tonya Patrice Bowers
• Bowman and Associates LLC (Perron Chiropractic)

• Medical Physician Assistant in Reston, VA
• Providers in Reston, VA by specialty
• Medical Physician Assistant in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.