Provider Demographics
NPI:1508488172
Name:DICICCO-BLOOM, JARED
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:
Last Name:DICICCO-BLOOM
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 1:1660 MADISON AVE APT 10A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3117
Mailing Address - Country:US
Mailing Address - Phone:609-651-3578
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 1003
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6639
Practice Address - Country:US
Practice Address - Phone:212-686-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-17
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health