Provider Demographics
NPI:1487667069
Name:SULLIVAN, JERI BOUDREAUX (MS)
Entity Type:Individual
Prefix:MRS
First Name:JERI
Middle Name:BOUDREAUX
Last Name:SULLIVAN
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:PO BOX 10076
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77710-0076
Mailing Address - Country:US
Mailing Address - Phone:409-880-8171
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROLFE CHRISTOPHER AND IOWA
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77710
Practice Address - Country:US
Practice Address - Phone:409-880-8171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14387235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist