Provider Demographics
NPI:1386004620
Name:BOONSTRA, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:1023 JONES ST APT 802
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-2937
Mailing Address - Country:US
Mailing Address - Phone:605-999-7356
Mailing Address - Fax:
Practice Address - Street 1:600 N 93RD ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2616
Practice Address - Country:US
Practice Address - Phone:402-391-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist