Provider Demographics
NPI:1518067701
Name:BLUME, JERRY (LICSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:BLUME
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 HIGHWAY 13 E
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2917
Mailing Address - Country:US
Mailing Address - Phone:952-894-4828
Mailing Address - Fax:952-894-3737
Practice Address - Street 1:1523 HIGHWAY 13 E
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2917
Practice Address - Country:US
Practice Address - Phone:952-894-4828
Practice Address - Fax:952-894-3737
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLICSW12647103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP34163OtherHEALTH PARTNERS
MN6261296OtherMEDICA UBH
MN340M8BLOtherMN BCBS