Provider Demographics
NPI:1801012992
Name:BOYD, JENNIFER ANNE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:BOYD
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 1:3063 CHARTWELL CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5826
Mailing Address - Country:US
Mailing Address - Phone:815-713-3281
Mailing Address - Fax:
Practice Address - Street 1:NIA 1515 S. MERIDIAN RD.
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102
Practice Address - Country:US
Practice Address - Phone:815-964-0937
Practice Address - Fax:815-964-2210
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJB57041298P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist