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General NPI Number Information
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NPI Number | 1619791415
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Entity Type | Organization
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Legal Business Name | PEDIATRIC NEURODEVELOPMENTAL & BEHAVIORAL CLINIC OF SOUTHERN OREGON
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Dates
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Enumeration Date | 11/09/2024
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Last Update Date | 11/09/2024
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Provider Practice Location Address
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Address Line | 33 N CENTRAL AVE STE 317
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City | MEDFORD
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State | OR
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Zip | 97501-5939
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Country | US
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Telephone | 541-227-2808
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Fax | 541-227-2807
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Provider Business Mailing Address
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Address Line | 33 N CENTRAL AVE STE 317
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City | MEDFORD
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State | OR
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Zip | 97501-5939
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Country | US
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Telephone | 541-227-2808
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Fax | 541-227-2807
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | JENNIFER BOUDREAUX
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Credential | MSN, CPNP, PMHS
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Telephone | 541-324-3648
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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