Provider Demographics
NPI:1558129841
Name:BLUM, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BLUM
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 1:6200 HABITAT DR APT 3046
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3237
Mailing Address - Country:US
Mailing Address - Phone:720-310-8184
Mailing Address - Fax:
Practice Address - Street 1:6200 HABITAT DR APT 3046
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3237
Practice Address - Country:US
Practice Address - Phone:720-310-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0021085101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COLPCC.0021085OtherDORA