Provider Demographics
NPI:1942898028
Name:BOESE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 LILLY RD NE STE 240
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5117
Mailing Address - Country:US
Mailing Address - Phone:360-413-3850
Mailing Address - Fax:360-359-4726
Practice Address - Street 1:1551 PROFESSIONAL LN UNIT 145
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6968
Practice Address - Country:US
Practice Address - Phone:720-494-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP032830T225100000X
COCP0369TT1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist