Provider Demographics
NPI:1922123645
Name:BOS, JON S (PSYD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:BOS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CENTER POINT RD STE 2350
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5826
Mailing Address - Country:US
Mailing Address - Phone:803-699-8887
Mailing Address - Fax:803-699-8824
Practice Address - Street 1:2000 CENTER POINT RD STE 2350
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5826
Practice Address - Country:US
Practice Address - Phone:803-699-8887
Practice Address - Fax:803-699-8824
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1382103G00000X
MI6301010098103G00000X
AR202170103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922123645OtherNPI
MI680D116880OtherBCBS PROVIDER I.D.