Provider Demographics
NPI:1073963328
Name:BLOOM, JESSICA MARYANNE (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARYANNE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARYANNE
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 PATTERSON ST STE 307
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-6532
Mailing Address - Country:US
Mailing Address - Phone:615-342-6900
Mailing Address - Fax:
Practice Address - Street 1:2400 PATTERSON ST STE 307
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-6532
Practice Address - Country:US
Practice Address - Phone:615-342-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN3674363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant