Provider Demographics
NPI:1003430802
Name:BLUME, JASON PRINZ
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:PRINZ
Last Name:BLUME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 NW CHARBONNEAU ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701
Mailing Address - Country:US
Mailing Address - Phone:541-591-5669
Mailing Address - Fax:
Practice Address - Street 1:750 NW CHARBONNEAU ST.
Practice Address - Street 2:SUITE 201
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701
Practice Address - Country:US
Practice Address - Phone:541-591-5669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORIN-10208105106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician