Provider Demographics
NPI:1689027781
Name:BOSLEY-SMITH, JASON (LDN, CNS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BOSLEY-SMITH
Suffix:
Gender:M
Credentials:LDN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 KERNAN DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6665
Mailing Address - Country:US
Mailing Address - Phone:410-448-6361
Mailing Address - Fax:410-448-1873
Practice Address - Street 1:2200 KERNAN DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-6665
Practice Address - Country:US
Practice Address - Phone:410-448-6361
Practice Address - Fax:410-448-1873
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3830133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist