Provider Demographics
NPI:1760027007
Name:BLOOM, JENNIFER (APRN, CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:160 HILL CIR W
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8821
Mailing Address - Country:US
Mailing Address - Phone:763-464-4551
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6506363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics