Provider Demographics
NPI:1366509754
Name:BOSCO, JAKKI (LMT)
Entity type:Individual
Prefix:
First Name:JAKKI
Middle Name:
Last Name:BOSCO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 ESCORT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-3451
Mailing Address - Country:US
Mailing Address - Phone:813-298-5603
Mailing Address - Fax:
Practice Address - Street 1:3910 NORTHDALE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1800
Practice Address - Country:US
Practice Address - Phone:813-298-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA45584225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC4124OtherBCBSF PROVIDER NUMBER