1144718537 NPI number — MRS. JENNIFER DAWN BOSTIC LAT/ATC, PTA

Table of content: MRS. JENNIFER DAWN BOSTIC LAT/ATC, PTA (NPI 1144718537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144718537 NPI number — MRS. JENNIFER DAWN BOSTIC LAT/ATC, PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSTIC
Provider First Name:
JENNIFER
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LAT/ATC, PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144718537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
476 W US HIGHWAY 50 STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERSAILLES
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47042-8340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-689-1771
Provider Business Mailing Address Fax Number:
812-689-1778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 W US HIGHWAY 50 STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERSAILLES
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47042-8340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-689-1771
Provider Business Practice Location Address Fax Number:
812-689-1778
Provider Enumeration Date:
05/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  36000064A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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