Provider Demographics
NPI:1417296898
Name:BOOTLE, JENNIFER BOYD (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BOYD
Last Name:BOOTLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14089 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1966
Mailing Address - Country:US
Mailing Address - Phone:912-350-2121
Mailing Address - Fax:912-350-2145
Practice Address - Street 1:14089 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1966
Practice Address - Country:US
Practice Address - Phone:912-350-2121
Practice Address - Fax:912-350-2145
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN227783363LF0000X
SC18172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003138354BMedicaid
GA003138354AMedicaid
GAP01241129OtherRAILROAD MEDICARE
GA003138354CMedicaid
GA003138354DMedicaid
GA202I502749Medicare PIN
GAP01241129OtherRAILROAD MEDICARE