Provider Demographics
NPI:1003112558
Name:J BOATMAN LLC
Entity Type:Organization
Organization Name:J BOATMAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:314-753-5184
Mailing Address - Street 1:5807 MANGO DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-2243
Mailing Address - Country:US
Mailing Address - Phone:314-753-5184
Mailing Address - Fax:
Practice Address - Street 1:11475 OLDE CABIN RD STE 120
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7128
Practice Address - Country:US
Practice Address - Phone:314-647-4488
Practice Address - Fax:314-647-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11805163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO580714OtherANTHEM BCBS
MO13350003Medicare PIN