1659891539 NPI number — JAMIE LOU BOYSEN LISW

Table of content: JAMIE LOU BOYSEN LISW (NPI 1659891539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659891539 NPI number — JAMIE LOU BOYSEN LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYSEN
Provider First Name:
JAMIE
Provider Middle Name:
LOU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSCH
Provider Other First Name:
JAMIE
Provider Other Middle Name:
LOU
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659891539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
180 10TH STREET SE, SUITE 201
Provider Second Line Business Mailing Address:
PO BOX 70
Provider Business Mailing Address City Name:
LE MARS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-546-4624
Provider Business Mailing Address Fax Number:
712-546-9395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 10TH STREET SE, SUITE 201
Provider Second Line Business Practice Location Address:
PO BOX 70
Provider Business Practice Location Address City Name:
LE MARS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51031-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-546-4624
Provider Business Practice Location Address Fax Number:
712-546-4624
Provider Enumeration Date:
06/22/2017

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: 104100000X , with the licence number:  081924 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0088088 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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