Basic Information
| Provider Information | |||||||||
| NPI: | 1417296898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTLE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BOYD | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14089 ABERCORN ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123502121 | ||||||||
| FaxNumber: | 9123502145 | ||||||||
| Practice Location | |||||||||
| Address1: | 14089 ABERCORN ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123502121 | ||||||||
| FaxNumber: | 9123502145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 11/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN227783 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 18172 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003138354B | 05 | GA | MEDICAID | 003138354A | 05 | GA | MEDICAID | P01241129 | 01 | GA | RAILROAD MEDICARE | OTHER | 003138354C | 05 | GA | MEDICAID | 003138354D | 05 | GA | MEDICAID |