Provider Demographics
NPI:1083221378
Name:BOECKMAN, JENNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BOECKMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1781 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARIA STEIN
Mailing Address - State:OH
Mailing Address - Zip Code:45860-9806
Mailing Address - Country:US
Mailing Address - Phone:419-305-7198
Mailing Address - Fax:
Practice Address - Street 1:11230 STATE ROUTE 364
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-9534
Practice Address - Country:US
Practice Address - Phone:419-394-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT014199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist