Healthcare Provider Details

I. General information

NPI: 1467751784
Provider Name (Legal Business Name): JAIE BOSSE ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2011
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S 17TH ST SUITE 2304-A
PHILADELPHIA PA
19103-6231
US

IV. Provider business mailing address

255 S 17TH ST SUITE 2304-A
PHILADELPHIA PA
19103-6231
US

V. Phone/Fax

Practice location:
  • Phone: 215-995-1247
  • Fax: 215-315-3655
Mailing address:
  • Phone: 215-995-1247
  • Fax: 215-315-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1765
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: