Provider Demographics
NPI:1427129592
Name:BOSTON, JESSICA BREN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BREN
Last Name:BOSTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 850
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4803
Mailing Address - Country:US
Mailing Address - Phone:310-828-7757
Mailing Address - Fax:310-594-5953
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 850
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4803
Practice Address - Country:US
Practice Address - Phone:310-828-7757
Practice Address - Fax:310-594-5953
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA791832081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I35910Medicare UPIN
CAWA79183AMedicare ID - Type Unspecified