Provider Demographics
NPI:1598010589
Name:BOUDREAUX, JAYME L (NP)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:L
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3765
Mailing Address - Country:US
Mailing Address - Phone:504-834-0626
Mailing Address - Fax:504-833-9480
Practice Address - Street 1:1200 AVENUE G
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3765
Practice Address - Country:US
Practice Address - Phone:504-349-6713
Practice Address - Fax:504-349-3733
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2305026Medicaid
LA247786YJJ4Medicare PIN