Provider Demographics
NPI:1548454382
Name:JAMIE J. BOUDREAU, LTD
Entity type:Organization
Organization Name:JAMIE J. BOUDREAU, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:815-933-4072
Mailing Address - Street 1:183 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1268
Mailing Address - Country:US
Mailing Address - Phone:815-933-4072
Mailing Address - Fax:815-933-5564
Practice Address - Street 1:183 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1268
Practice Address - Country:US
Practice Address - Phone:815-933-4072
Practice Address - Fax:815-933-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004623038OtherBC/BS OF ILLINOIS