MEDICARE: DR. JENNIFER ERIN EARL-BOEHM PHD, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	515-039	WI

General Provider Information

NPI Number	:	1497140123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER ERIN EARL-BOEHM PHD, ATC

Provider Business Mailing Address
First Line	:	PO BOX 413
Second Line	:	PAVILION SUITE 350
City	:	MILWAUKEE
State	:	WI
Zip	:	53201-0413
Country	:	US
Telephone Number	:	414-229-3227
Fax Number	:	414-229-3366

Provider Business Practice Location Address
First Line	:	3409 N DOWNER AVE
Second Line	:	PAVILION SUITE 350
City	:	MILWAUKEE
State	:	WI
Zip	:	53211
Country	:	US
Telephone Number	:	414-229-3227
Fax Number	:	414-229-3366

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2015
Last Update Date	:	03/31/2015

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