Provider Demographics
NPI:1073522959
Name:BOULDIN, JANE D (MS)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:D
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 COUNTY ROAD 630
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:AL
Mailing Address - Zip Code:35984-2208
Mailing Address - Country:US
Mailing Address - Phone:256-634-4225
Mailing Address - Fax:
Practice Address - Street 1:2409 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2207
Practice Address - Country:US
Practice Address - Phone:256-582-3203
Practice Address - Fax:256-582-3216
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51528248OtherBCBS