Provider Demographics
NPI:1730712308
Name:BLOOM, JAKE B (LPC)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:B
Last Name:BLOOM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 BALLENTINE RD
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3740
Mailing Address - Country:US
Mailing Address - Phone:715-505-0101
Mailing Address - Fax:
Practice Address - Street 1:4076 KOTHLOW AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3090
Practice Address - Country:US
Practice Address - Phone:715-235-4537
Practice Address - Fax:715-235-4535
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4058-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health