Provider Demographics
NPI:1568554608
Name:TAYLOR, JENNIFER PATRICIA (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:PATRICIA
Other - Last Name:BOUDREAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5341 BAYOU DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5408
Mailing Address - Country:US
Mailing Address - Phone:850-529-8057
Mailing Address - Fax:
Practice Address - Street 1:5341 BAYOU DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-5408
Practice Address - Country:US
Practice Address - Phone:850-529-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767860600Medicaid