MEDICARE: JACOB BOESE

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	225100000X	Physical Therapist	CP0369TT1	CO
2	225100000X	Physical Therapist	PT.PT.61590626-CP	WA
3	225100000X	Physical Therapist	CP046626T	OH

General Provider Information

NPI Number	:	1942898028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB BOESE

Provider Business Mailing Address
First Line	:	615 LILLY RD NE STE 240
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-5117
Country	:	US
Telephone Number	:	360-413-3850
Fax Number	:	360-359-4726

Provider Business Practice Location Address
First Line	:	615 LILLY RD NE STE 240
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-5117
Country	:	US
Telephone Number	:	360-413-3850
Fax Number	:	360-359-4726

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

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	04/08/2026

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615 LILLY RD NE STE 240
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1396775896 — YOSHIHIRO YAMAMOTO M.D.
Practice Location Address:

615 LILLY RD NE , STE. 100
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1972536779 — MRS. LORI ANNE CARDWELL PA-C
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1164441820 — NANCY P NELSON ARNP
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615 LILLY RD NE , SUITE 140
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Directions to “ JACOB BOESE ” Practice Location

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