Provider Demographics
NPI:1174890867
Name:BOOSHU, JILL (CHA IV)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BOOSHU
Suffix:
Gender:F
Credentials:CHA IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 CLINIC ROAD
Mailing Address - Street 2:BOX 190
Mailing Address - City:GAMBELL
Mailing Address - State:AK
Mailing Address - Zip Code:99742-0190
Mailing Address - Country:US
Mailing Address - Phone:907-985-5015
Mailing Address - Fax:907-985-5085
Practice Address - Street 1:190 CLINIC ROAD
Practice Address - Street 2:BOX 190
Practice Address - City:GAMBELL
Practice Address - State:AK
Practice Address - Zip Code:99742-0190
Practice Address - Country:US
Practice Address - Phone:907-985-5015
Practice Address - Fax:907-985-5085
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK03-602-IV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-IVOther03-602-IV