Provider Demographics
NPI:1467741868
Name:BOUR, JASON B (CLC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:B
Last Name:BOUR
Suffix:
Gender:M
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SUFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167
Mailing Address - Country:US
Mailing Address - Phone:615-534-2500
Mailing Address - Fax:
Practice Address - Street 1:209 CASTLEWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-5163
Practice Address - Country:US
Practice Address - Phone:615-534-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker