Healthcare Provider Details

I. General information

NPI: 1669665626
Provider Name (Legal Business Name): JENNA BOERBOOM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17650 140TH AVE SE #B-07
RENTON WA
98058-6814
US

IV. Provider business mailing address

244 118TH AVE SE APT 28
BELLEVUE WA
98005-3560
US

V. Phone/Fax

Practice location:
  • Phone: 425-430-0700
  • Fax: 425-430-0710
Mailing address:
  • Phone: 319-270-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00010556
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0014633
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: