Provider Demographics
NPI:1508154337
Name:BOEHM, JOHN JASON (MS, CNS, MMC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JASON
Last Name:BOEHM
Suffix:
Gender:M
Credentials:MS, CNS, MMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4364 N. KENMORE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1394
Mailing Address - Country:US
Mailing Address - Phone:917-292-1100
Mailing Address - Fax:
Practice Address - Street 1:4364 N. KENMORE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1394
Practice Address - Country:US
Practice Address - Phone:917-292-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist