Provider Demographics
NPI:1467837856
Name:BOSWELL, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOSWELL
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 1:238 STREET RD
Mailing Address - Street 2:APARTMENT C201
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3172
Mailing Address - Country:US
Mailing Address - Phone:215-364-0500
Mailing Address - Fax:215-942-2578
Practice Address - Street 1:238 STREET RD
Practice Address - Street 2:APARTMENT C201
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3172
Practice Address - Country:US
Practice Address - Phone:215-364-0500
Practice Address - Fax:215-942-2578
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPO15151363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASPO15151OtherLICENSE
PAAG0715011OtherCERTIFICATION