Provider Demographics
NPI:1669665626
Name:BOERBOOM, JENNA (DPT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BOERBOOM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 118TH AVE SE
Mailing Address - Street 2:APT 28
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3560
Mailing Address - Country:US
Mailing Address - Phone:319-270-4756
Mailing Address - Fax:
Practice Address - Street 1:17650 140TH AVE SE
Practice Address - Street 2:#B-07
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-6814
Practice Address - Country:US
Practice Address - Phone:425-430-0700
Practice Address - Fax:425-430-0710
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010556225100000X
COPTL0014633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8870253OtherMEDICARE ID