Provider Demographics
NPI:1447064019
Name:BOODT, JENNIFER C (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:BOODT
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 1:3371 HAMPTON DOWNS DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-8091
Mailing Address - Country:US
Mailing Address - Phone:269-876-8242
Mailing Address - Fax:
Practice Address - Street 1:6769 COURTLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7242
Practice Address - Country:US
Practice Address - Phone:616-863-9482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501006322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty