Provider Demographics
NPI:1689977498
Name:BOUSTEAD, JENNIFER SUTTON (OTR)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUTTON
Last Name:BOUSTEAD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 REFINERY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-2111
Mailing Address - Country:US
Mailing Address - Phone:940-665-0386
Mailing Address - Fax:
Practice Address - Street 1:1907 REFINERY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-2111
Practice Address - Country:US
Practice Address - Phone:940-665-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110293174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist