Provider Demographics
NPI:1962422873
Name:BOEVERS, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOEVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:BRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:309 S CHERRY STREET
Practice Address - Street 2:
Practice Address - City:SHELL ROCK
Practice Address - State:IA
Practice Address - Zip Code:50670
Practice Address - Country:US
Practice Address - Phone:319-885-4363
Practice Address - Fax:319-885-6583
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0484303Medicaid
IA0484303Medicaid
IAI17342Medicare PIN