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NPI Code Detail

MEDICARE: JERRA-LYNN BOUDJOUK CCC-SLP

MEDICARE: JERRA-LYNN BOUDJOUK CCC-SLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1235Z00000XSpeech-Language Pathologist7510MN

General Provider Information

NPI Number : 1033201371
Entity Type Code : Individual
Provider Name (Legal Business Name) : JERRA-LYNN BOUDJOUK CCC-SLP
Provider Business Mailing Address
First Line : 1250 W BROADWAY AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55411-2533
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1250 W BROADWAY AVE
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55411-2533
Country : US
Telephone Number : 612-668-2000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2006
Last Update Date : 12/10/2025

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Directions to “ JERRA-LYNN BOUDJOUK CCC-SLP” Practice Location

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