Provider Demographics
NPI:1558611079
Name:BLOOM, JERRY LYNN (BS, CADC)
Entity Type:Individual
Prefix:
First Name:JERRY LYNN
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:BS, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-5001
Mailing Address - Country:US
Mailing Address - Phone:319-752-4000
Mailing Address - Fax:319-752-6933
Practice Address - Street 1:724 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-5001
Practice Address - Country:US
Practice Address - Phone:319-752-4000
Practice Address - Fax:319-752-6933
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05002104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker