Provider Demographics
NPI:1174702583
Name:BLOOM, JESSICA ANN
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5617 VON AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-6044
Mailing Address - Country:US
Mailing Address - Phone:815-953-4023
Mailing Address - Fax:708-534-7715
Practice Address - Street 1:5617 W VON AVE UNIT C
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-7917
Practice Address - Country:US
Practice Address - Phone:815-953-4023
Practice Address - Fax:708-534-7715
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB45042183855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist