Provider Demographics
NPI:1972988210
Name:BOEDER, JESS SEYMOUR (MS, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:SEYMOUR
Last Name:BOEDER
Suffix:
Gender:M
Credentials:MS, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13176 W PERSIMMON LN
Mailing Address - Street 2:STE. 120
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5063
Mailing Address - Country:US
Mailing Address - Phone:208-376-3591
Mailing Address - Fax:208-376-3594
Practice Address - Street 1:13176 W PERSIMMON LN
Practice Address - Street 2:STE. 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5063
Practice Address - Country:US
Practice Address - Phone:208-376-3591
Practice Address - Fax:208-376-3594
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist