=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437619541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA SANDRA WONG-BOYTER DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2019
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1319 LEAVENWORTH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68102-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-552-3222
-----------------------------------------------------
Fax | 402-552-2172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1319 LEAVENWORTH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68102-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-552-3222
-----------------------------------------------------
Fax | 402-552-2172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2024046596
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------