Healthcare Provider Details

I. General information

NPI: 1922404912
Provider Name (Legal Business Name): JEANIE WOOLLEDGE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 E CANAL ST
PICAYUNE MS
39466-4500
US

IV. Provider business mailing address

32 PATRICE RD
PICAYUNE MS
39466-8159
US

V. Phone/Fax

Practice location:
  • Phone: 504-628-4882
  • Fax:
Mailing address:
  • Phone: 504-628-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3235
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: