Healthcare Provider Details

I. General information

NPI: 1689027781
Provider Name (Legal Business Name): JASON BOSLEY-SMITH LDN, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KERNAN DR 2ND FLOOR
BALTIMORE MD
21207-6665
US

IV. Provider business mailing address

2200 KERNAN DR 2ND FLOOR
BALTIMORE MD
21207-6665
US

V. Phone/Fax

Practice location:
  • Phone: 410-448-6361
  • Fax: 410-448-1873
Mailing address:
  • Phone: 410-448-6361
  • Fax: 410-448-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX3830
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: