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General NPI Number Information
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NPI Number | 1366515702
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Entity Type | Individual
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Provider Name | JERRY PAUL BOUDREAUX L C S W
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 549 E PASS RD SUITE P
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City | GULFPORT
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State | MS
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Zip | 39507-3261
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Country | US
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Telephone | 228-896-9251
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Fax | 228-897-6003
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Provider Business Mailing Address
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Address Line | 549 E PASS RD SUITE P
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City | GULFPORT
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State | MS
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Zip | 39507-3261
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Country | US
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Telephone | 228-896-9251
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Fax | 228-897-6003
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0058
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License Number State | MS
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