Provider Demographics
NPI:1114501004
Name:BOSTON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOSTON
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 1:16430 BATSON RD
Mailing Address - Street 2:
Mailing Address - City:SPENCERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20868-9705
Mailing Address - Country:US
Mailing Address - Phone:202-905-8667
Mailing Address - Fax:
Practice Address - Street 1:4430 BENNING RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-4555
Practice Address - Country:US
Practice Address - Phone:202-235-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG50083709104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty