Provider Demographics
NPI:1114539418
Name:BOUDREAUX, JOHNATHAN ORY (DC)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:ORY
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 STERLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2519
Mailing Address - Country:US
Mailing Address - Phone:318-387-5388
Mailing Address - Fax:
Practice Address - Street 1:3219 STERLINGTON RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2519
Practice Address - Country:US
Practice Address - Phone:318-387-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1913111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor