Provider Demographics
NPI:1558928580
Name:BLUM, JONATHON EDWARD (NP)
Entity Type:Individual
Prefix:MR
First Name:JONATHON
Middle Name:EDWARD
Last Name:BLUM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-1130
Mailing Address - Country:US
Mailing Address - Phone:907-783-1355
Mailing Address - Fax:907-783-1357
Practice Address - Street 1:131 LINDBLAD AVE.
Practice Address - Street 2:
Practice Address - City:GIRDWOOD
Practice Address - State:AK
Practice Address - Zip Code:99587-1130
Practice Address - Country:US
Practice Address - Phone:907-783-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402628363LP0808X
AK166885363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health