Provider Demographics
NPI:1235674490
Name:BLOM, JENNIFER M (MSN, CRNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BLOM
Suffix:
Gender:F
Credentials:MSN, CRNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 FERNCROFT LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER SPRINGS
Mailing Address - State:PA
Mailing Address - Zip Code:19425-3847
Mailing Address - Country:US
Mailing Address - Phone:985-516-7433
Mailing Address - Fax:215-600-3613
Practice Address - Street 1:2133 FERNCROFT LN
Practice Address - Street 2:
Practice Address - City:CHESTER SPRINGS
Practice Address - State:PA
Practice Address - Zip Code:19425-3847
Practice Address - Country:US
Practice Address - Phone:985-516-7433
Practice Address - Fax:215-600-3613
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016868363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health