Provider Demographics
NPI:1619791415
Name:PEDIATRIC NEURODEVELOPMENTAL & BEHAVIORAL CLINIC OF SOUTHERN OREGON
Entity type:Organization
Organization Name:PEDIATRIC NEURODEVELOPMENTAL & BEHAVIORAL CLINIC OF SOUTHERN OREGON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, CPNP, PMHS
Authorized Official - Phone:541-324-3648
Mailing Address - Street 1:33 N CENTRAL AVE STE 317
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5939
Mailing Address - Country:US
Mailing Address - Phone:541-227-2808
Mailing Address - Fax:541-227-2807
Practice Address - Street 1:33 N CENTRAL AVE STE 317
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5939
Practice Address - Country:US
Practice Address - Phone:541-227-2808
Practice Address - Fax:541-227-2807
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JENNIFER K BOUDREAUX, CPNP, PMHS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health