Provider Demographics
NPI:1982063285
Name:BLOSSOM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35105 KENAI SPUR HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7658
Mailing Address - Country:US
Mailing Address - Phone:907-260-7444
Mailing Address - Fax:907-260-7400
Practice Address - Street 1:35105 KENAI SPUR HWY
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7658
Practice Address - Country:US
Practice Address - Phone:907-260-7444
Practice Address - Fax:907-260-7400
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107413225X00000X
WAOT61180260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist