Healthcare Provider Details

I. General information

NPI: 1700699816
Provider Name (Legal Business Name): JERAD DUMOLT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVE
BOSTON MA
02118-2309
US

IV. Provider business mailing address

1 NASHUA ST APT 1409
BOSTON MA
02114-1618
US

V. Phone/Fax

Practice location:
  • Phone: 281-636-9926
  • Fax:
Mailing address:
  • Phone: 281-636-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberLDN7037
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberLDN7037
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: