Healthcare Provider Details

I. General information

NPI: 1700614856
Provider Name (Legal Business Name): JASON BRODO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 W LANCASTER AVE
DEVON PA
19333-1592
US

IV. Provider business mailing address

316 ROSEMARY LN
PENN VALLEY PA
19072-1120
US

V. Phone/Fax

Practice location:
  • Phone: 484-693-0660
  • Fax:
Mailing address:
  • Phone: 215-756-1009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN008517
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: