Provider Demographics
NPI:1942961248
Name:BLOOM, JENNIFER ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 12TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4625
Mailing Address - Country:US
Mailing Address - Phone:424-275-7252
Mailing Address - Fax:
Practice Address - Street 1:1833 12TH ST APT B
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4625
Practice Address - Country:US
Practice Address - Phone:424-275-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141174106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT141174OtherBBS LMFT REGISTRATION