Provider Demographics
NPI:1891899399
Name:BOSTON, JENNIFER NOEL (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NOEL
Last Name:BOSTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7759 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6742
Mailing Address - Country:US
Mailing Address - Phone:317-359-1215
Mailing Address - Fax:317-359-1235
Practice Address - Street 1:321 E NORTHFIELD DRIVE
Practice Address - Street 2:#200
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112
Practice Address - Country:US
Practice Address - Phone:317-852-1771
Practice Address - Fax:317-852-1782
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006968A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
318840Medicare ID - Type Unspecified