Provider Demographics
NPI:1245643592
Name:BOSTOCK, JATOYA
Entity type:Individual
Prefix:
First Name:JATOYA
Middle Name:
Last Name:BOSTOCK
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 1:4932 HACKETT DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-6237
Mailing Address - Country:US
Mailing Address - Phone:937-718-3322
Mailing Address - Fax:
Practice Address - Street 1:4932 HACKETT DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-6237
Practice Address - Country:US
Practice Address - Phone:937-718-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications