Provider Demographics
NPI:1144718537
Name:BOSTIC, JENNIFER DAWN (LAT/ATC, PTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DAWN
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:LAT/ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 W US HIGHWAY 50 STE A
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:IN
Mailing Address - Zip Code:47042-8340
Mailing Address - Country:US
Mailing Address - Phone:812-689-1771
Mailing Address - Fax:812-689-1778
Practice Address - Street 1:476 W US HIGHWAY 50 STE A
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:IN
Practice Address - Zip Code:47042-8340
Practice Address - Country:US
Practice Address - Phone:812-689-1771
Practice Address - Fax:812-689-1778
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000064A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer