Provider Demographics
NPI:1407306517
Name:BLOOM, JACY (DC MS)
Entity Type:Individual
Prefix:DR
First Name:JACY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DC MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BRENTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-4652
Mailing Address - Country:US
Mailing Address - Phone:386-453-1839
Mailing Address - Fax:
Practice Address - Street 1:2190 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5040
Practice Address - Country:US
Practice Address - Phone:941-493-2688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11985111N00000X
FLCH11985111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor