Provider Demographics
NPI:1013045855
Name:BOATMAN, JACKIE LYNN
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:LYNN
Last Name:BOATMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 BROOKS BND
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9235
Mailing Address - Country:US
Mailing Address - Phone:317-858-8130
Mailing Address - Fax:317-858-8130
Practice Address - Street 1:219 BROOKS BND
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-9235
Practice Address - Country:US
Practice Address - Phone:317-858-8130
Practice Address - Fax:317-858-8130
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN311447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist