Provider Demographics
NPI:1225216518
Name:FOGLER, JASON M (PHD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:FOGLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BURNSIDE RD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-1949
Mailing Address - Country:US
Mailing Address - Phone:781-444-2052
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:FEGAN 10
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NH1184103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health