Healthcare Provider Details

I. General information

NPI: 1861604431
Provider Name (Legal Business Name): JASON GRUNDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/06/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N POINT BLVD STE 131
BALTIMORE MD
21224-3417
US

IV. Provider business mailing address

10440 LITTLE PATUXENT PKWY STE 800
COLUMBIA MD
21044-3569
US

V. Phone/Fax

Practice location:
  • Phone: 410-508-0722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR145701
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025000569
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: