Provider Demographics
NPI:1003163858
Name:BOSTICK, JERRELL S (BS)
Entity Type:Individual
Prefix:
First Name:JERRELL
Middle Name:S
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 RAILWAY ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2654
Mailing Address - Country:US
Mailing Address - Phone:386-679-8532
Mailing Address - Fax:
Practice Address - Street 1:504 RAILWAY ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2654
Practice Address - Country:US
Practice Address - Phone:386-679-8532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-11
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TXMT135450225700000X
FLMA79474225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator