=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700292000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BOOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2014
-----------------------------------------------------
Last Update Date | 07/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2045 WESTGATE DR SUITE100
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18017-7480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 187-799-8543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 PINE ST
-----------------------------------------------------
City | PEN ARGYL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18072-1340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------