Provider Demographics
NPI:1881724284
Name:BLOOM, JENNIFER R (CNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:BLOOM-LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6680 POE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2855
Mailing Address - Country:US
Mailing Address - Phone:937-280-8400
Mailing Address - Fax:
Practice Address - Street 1:8881 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1333
Practice Address - Country:US
Practice Address - Phone:937-293-1622
Practice Address - Fax:937-245-6308
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-241081 NP-08754363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health