Basic Information
| Provider Information | |||||||||
| NPI: | 1962422873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOEVERS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2101 KIMBALL AVE | ||||||||
| Address2: | LL14 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192721590 | ||||||||
| FaxNumber: | 3192721535 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 S CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | SHELL ROCK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198854363 | ||||||||
| FaxNumber: | 3198856583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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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 | 207Q00000X | 33143 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0484303 | 05 | IA | MEDICAID |