Healthcare Provider Details

I. General information

NPI: 1720454549
Provider Name (Legal Business Name): DR. JESSICA BOISJOLI LEBOEUF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2015
Last Update Date: 08/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 HISTORIAN ST
RALEIGH NC
27603-3489
US

IV. Provider business mailing address

824 HISTORIAN ST
RALEIGH NC
27603-3489
US

V. Phone/Fax

Practice location:
  • Phone: 919-274-1988
  • Fax:
Mailing address:
  • Phone: 919-274-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4215
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number4215
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: