Provider Demographics
NPI:1841319415
Name:BOODEN, JACK JR (CPO)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BOODEN
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1422
Mailing Address - Country:US
Mailing Address - Phone:757-627-4191
Mailing Address - Fax:757-627-8709
Practice Address - Street 1:2418 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1422
Practice Address - Country:US
Practice Address - Phone:757-627-4191
Practice Address - Fax:757-627-8709
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CPO 00503222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795231Medicare UPIN