Healthcare Provider Details

I. General information

NPI: 1295185692
Provider Name (Legal Business Name): JESSICA BORNE BOUDREAUX MOT, LOTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE BORNE MOT, LOTR

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1054 CANAL BLVD
THIBODAUX LA
70301-4544
US

IV. Provider business mailing address

622 HIGHWAY 20
THIBODAUX LA
70301-6229
US

V. Phone/Fax

Practice location:
  • Phone: 985-665-7575
  • Fax:
Mailing address:
  • Phone: 985-859-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number301778
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: