Provider Demographics
NPI:1467015008
Name:BOESINGER, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BOESINGER
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 1:1266 ROMANE DR
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1652
Mailing Address - Country:US
Mailing Address - Phone:330-352-6775
Mailing Address - Fax:
Practice Address - Street 1:1266 ROMANE DR
Practice Address - Street 2:
Practice Address - City:SAGAMORE HILLS
Practice Address - State:OH
Practice Address - Zip Code:44067-1652
Practice Address - Country:US
Practice Address - Phone:330-352-6775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services