Provider Demographics
NPI:1558593012
Name:BOITA, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOITA
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 1:4605 MANZANITA ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4693
Mailing Address - Country:US
Mailing Address - Phone:541-515-6989
Mailing Address - Fax:
Practice Address - Street 1:1142 WILLAGILLESPIE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2142
Practice Address - Country:US
Practice Address - Phone:541-255-2681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1047580174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist