Healthcare Provider Details

I. General information

NPI: 1174647432
Provider Name (Legal Business Name): DR. CHARLES ANTHONY BOUDREAUX JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 N STATE ST
JACKSON MS
39201-1108
US

IV. Provider business mailing address

301 REMINGTON DR
BRANDON MS
39042-2865
US

V. Phone/Fax

Practice location:
  • Phone: 601-949-1949
  • Fax: 601-714-6922
Mailing address:
  • Phone: 601-949-1949
  • Fax: 601-714-6922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0980
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0023
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: