Provider Demographics
NPI:1649394156
Name:BOSTON, JEFFREY THEODORE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:THEODORE
Last Name:BOSTON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1821 UNIVERSITY AVE W
Mailing Address - Street 2:STE 155
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2880
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1503
Practice Address - Country:US
Practice Address - Phone:651-642-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3768103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245L9BOOtherBLUE CROSS BLUE SHIELD
MN184314100Medicaid