1497140123 NPI number — DR. JENNIFER ERIN EARL-BOEHM PHD, ATC

Table of content: DR. JENNIFER ERIN EARL-BOEHM PHD, ATC (NPI 1497140123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497140123 NPI number — DR. JENNIFER ERIN EARL-BOEHM PHD, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARL-BOEHM
Provider First Name:
JENNIFER
Provider Middle Name:
ERIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, ATC
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:
1497140123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 413
Provider Second Line Business Mailing Address:
PAVILION SUITE 350
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53201-0413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-229-3227
Provider Business Mailing Address Fax Number:
414-229-3366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3409 N DOWNER AVE
Provider Second Line Business Practice Location Address:
PAVILION SUITE 350
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-229-3227
Provider Business Practice Location Address Fax Number:
414-229-3366
Provider Enumeration Date:
03/31/2015

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:  515-039 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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