Provider Demographics
NPI:1053784918
Name:BOULDIN, SHERRY (LPC)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12195
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-2195
Mailing Address - Country:US
Mailing Address - Phone:601-292-6260
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5930
Practice Address - Country:US
Practice Address - Phone:601-927-8729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-01
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1995101YM0800X, 102L00000X, 103K00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst