MEDICARE: JEFFREY BLOSSER M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1700277787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY BLOSSER M.A.

Provider Business Mailing Address
First Line	:	312 1/2 S. 5TH STREET
Second Line	:	APARTMENT B
City	:	GOSHEN
State	:	IN
Zip	:	46528
Country	:	US
Telephone Number	:	574-329-3984
Fax Number	:

Provider Business Practice Location Address
First Line	:	2426 E PIERCETON RD
Second Line	:
City	:	WINONA LAKE
State	:	IN
Zip	:	46590-5713
Country	:	US
Telephone Number	:	574-269-7990
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	02/11/2015

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