Healthcare Provider Details

I. General information

NPI: 1053784918
Provider Name (Legal Business Name): SHERRY BOULDIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2015
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N SUITE 220
JACKSON MS
39211-5930
US

IV. Provider business mailing address

PO BOX 12195
JACKSON MS
39236-2195
US

V. Phone/Fax

Practice location:
  • Phone: 601-927-8729
  • Fax:
Mailing address:
  • Phone: 601-292-6260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1995
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1995
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1995
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number1995
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1995
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: