Provider Demographics
NPI:1184724783
Name:BLOOM, JAN HETTIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:HETTIE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23 MOFFAT RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1112
Mailing Address - Country:US
Mailing Address - Phone:617-243-6327
Mailing Address - Fax:617-244-4558
Practice Address - Street 1:4 - 8 HARTFORD STREET
Practice Address - Street 2:
Practice Address - City:NEWTON HIGHLANDS
Practice Address - State:MA
Practice Address - Zip Code:02461-1913
Practice Address - Country:US
Practice Address - Phone:617-243-6327
Practice Address - Fax:617-244-4558
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3381103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist