Provider Demographics
NPI:1609414440
Name:BOYLAN, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BOYLAN
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 1:300 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3124
Mailing Address - Country:US
Mailing Address - Phone:260-417-9540
Mailing Address - Fax:260-454-2083
Practice Address - Street 1:300 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3124
Practice Address - Country:US
Practice Address - Phone:260-417-9540
Practice Address - Fax:260-454-2083
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001789A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant