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General NPI Number Information
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NPI Number | 1952435463
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Entity Type | Individual
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Provider Name | JERRY WAYNE BOSTON L.C.S.W.
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Gender | Male
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2420 E 10TH ST
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City | JEFFERSONVILLE
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State | IN
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Zip | 47130-7303
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Country | US
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Telephone | 812-282-8248
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Fax | 812-282-3291
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Provider Business Mailing Address
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Address Line | 1106 SANDSTONE DR
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City | JEFFERSONVILLE
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State | IN
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Zip | 47130-8448
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Country | US
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Telephone | 812-284-3878
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 34005200A
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License Number State | IN
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