Provider Demographics
NPI:1083851802
Name:BOADA, JENNIFER L (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BOADA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 MICHIGAN CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1363
Mailing Address - Country:US
Mailing Address - Phone:808-372-6434
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY ROAD
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1014023363L00000X
VA0024165714363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner