Provider Demographics
NPI:1952649477
Name:BLOMMEL, JEFFREY W (PC,CDCA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BLOMMEL
Suffix:
Gender:M
Credentials:PC,CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:4TH FLOOR, NW BLDG
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-734-8339
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:4TH FLOOR, NW BLDG
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:937-734-8339
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1100287101YA0400X, 101Y00000X
OHCDCA.110594101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)