MEDICARE: MS. JENNIFER ANN BOECKEL MSW, LCSW

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	104100000X	Social Worker	4087	ND

General Provider Information

NPI Number	:	1306068176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER ANN BOECKEL MSW, LCSW

Provider Business Mailing Address
First Line	:	2644 36TH AVE S APT 214
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-5167
Country	:	US
Telephone Number	:	701-235-3643
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 NODAK DR S
Second Line	:	SUITE 200
City	:	FARGO
State	:	ND
Zip	:	58103-2366
Country	:	US
Telephone Number	:	701-280-9545
Fax Number	:

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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