Provider Demographics
NPI:1518102201
Name:BOONE, JENNIFER JO (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1942
Mailing Address - Country:US
Mailing Address - Phone:260-726-5656
Mailing Address - Fax:
Practice Address - Street 1:6040 W 84TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1360
Practice Address - Country:US
Practice Address - Phone:317-956-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBS508ZMedicare PIN