Provider Demographics
NPI:1790247757
Name:BOUDREAUX, JEREMY PAUL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:PAUL
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N SHERMAN AVE STE 24
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4457
Mailing Address - Country:US
Mailing Address - Phone:608-445-2510
Mailing Address - Fax:262-293-9777
Practice Address - Street 1:615 N SHERMAN AVE STE 24
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4457
Practice Address - Country:US
Practice Address - Phone:608-445-2510
Practice Address - Fax:262-293-9777
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI221281041C0700X
IL1490206711041C0700X
WI10072-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical