Provider Demographics
NPI:1093246589
Name:JENNIFER L. THIBODEAUX, PLLC
Entity Type:Organization
Organization Name:JENNIFER L. THIBODEAUX, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:THIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:225-270-2727
Mailing Address - Street 1:2653 MCCORMICK DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1041
Mailing Address - Country:US
Mailing Address - Phone:225-270-2727
Mailing Address - Fax:
Practice Address - Street 1:2653 MCCORMICK DR
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1041
Practice Address - Country:US
Practice Address - Phone:225-270-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9698103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty