Provider Demographics
NPI:1356672190
Name:BOAZZO GLENN, JENNA MARIE (DC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:BOAZZO GLENN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-9424
Mailing Address - Country:US
Mailing Address - Phone:630-360-4040
Mailing Address - Fax:
Practice Address - Street 1:39A STONEHILL RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9449
Practice Address - Country:US
Practice Address - Phone:630-360-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor