Provider Demographics
NPI:1023902012
Name:BOUTWELL, JO-ANNA ELIZABETH
Entity type:Individual
Prefix:
First Name:JO-ANNA
Middle Name:ELIZABETH
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 DURDEN ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-4608
Mailing Address - Country:US
Mailing Address - Phone:912-253-6595
Mailing Address - Fax:
Practice Address - Street 1:204 DURDEN ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-4608
Practice Address - Country:US
Practice Address - Phone:912-253-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT002127101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor