Healthcare Provider Details

I. General information

NPI: 1851847198
Provider Name (Legal Business Name): JESSICA M BOOZE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 DORCHESTER AVE
CAMBRIDGE MD
21613-2425
US

IV. Provider business mailing address

501 FAIRMONT AVE. SUITE 302
TOWSON MD
21286
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-5100
  • Fax: 410-228-7479
Mailing address:
  • Phone: 844-748-6878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA00378
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ3-0000476
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: