Provider Demographics
NPI:1235461500
Name:BOYETTE, JERRY STEPHEN
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:STEPHEN
Last Name:BOYETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:DIANE
Other - Last Name:BOYETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3944 CEDAR COVE LANE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257
Mailing Address - Country:US
Mailing Address - Phone:904-608-1077
Mailing Address - Fax:904-288-7716
Practice Address - Street 1:3944 CEDAR COVE LANE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257
Practice Address - Country:US
Practice Address - Phone:904-608-1077
Practice Address - Fax:904-288-7716
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies