Healthcare Provider Details

I. General information

NPI: 1952435463
Provider Name (Legal Business Name): JERRY WAYNE BOSTON L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-7303
US

IV. Provider business mailing address

1106 SANDSTONE DR
JEFFERSONVILLE IN
47130-8448
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-8248
  • Fax: 812-282-3291
Mailing address:
  • Phone: 812-284-3878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005200A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: