Basic Information
| Provider Information | |||||||||
| NPI: | 1386815835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX-MILLIGAN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2290 W EAU GALLIE BLVD STE 210B | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214351505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2290 W EAU GALLIE BLVD STE 210B | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214351505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 04/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9109966 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 2008006639 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.