Provider Demographics
NPI:1205223088
Name:BOOMSMA, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:BOOMSMA
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 1:7770 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-8650
Mailing Address - Country:US
Mailing Address - Phone:616-690-1241
Mailing Address - Fax:
Practice Address - Street 1:2786 56TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8708
Practice Address - Country:US
Practice Address - Phone:616-261-3960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202000514224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant