Provider Demographics
NPI:1851996581
Name:BLOOM, JORDAN (RN, BSN, APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:RN, BSN, APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6643 N HAMILTON CIR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7150
Mailing Address - Country:US
Mailing Address - Phone:763-777-0925
Mailing Address - Fax:
Practice Address - Street 1:6362 207TH ST N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-8022
Practice Address - Country:US
Practice Address - Phone:763-777-0925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30535367500000X
MN2318237163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered