Provider Demographics
NPI:1366820474
Name:BLUM, JENNIFER E (PSYD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BLUM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JENNIFER BLUM PSYD
Other - Middle Name:LICENSED
Other - Last Name:PSYCHOLOGIST PC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1144 SONOMA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4812
Mailing Address - Country:US
Mailing Address - Phone:707-968-7637
Mailing Address - Fax:
Practice Address - Street 1:1144 SONOMA AVE
Practice Address - Street 2:104
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4812
Practice Address - Country:US
Practice Address - Phone:707-331-4769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27164103TC0700X
CAPSY27164103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical