Provider Demographics
NPI:1811750730
Name:BOSTICK, JURLEE LOUISE
Entity type:Individual
Prefix:
First Name:JURLEE
Middle Name:LOUISE
Last Name:BOSTICK
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 1:25000 ROCKSIDE RD APT 745
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25000 ROCKSIDE RD APT 745
Practice Address - Street 2:
Practice Address - City:BEDFORD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44146-1929
Practice Address - Country:US
Practice Address - Phone:216-327-5468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSDI47177172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver