Provider Demographics
NPI:1386815835
Name:BOUDREAUX-MILLIGAN, JESSICA L (PA-C)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:BOUDREAUX-MILLIGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 W EAU GALLIE BLVD STE 210B
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3145
Mailing Address - Country:US
Mailing Address - Phone:321-435-1505
Mailing Address - Fax:
Practice Address - Street 1:2290 W EAU GALLIE BLVD STE 210B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-435-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9109966363AM0700X
MO2008006639363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL567730009Medicare PIN
MO000097533Medicare PIN