Healthcare Provider Details

I. General information

NPI: 1295425320
Provider Name (Legal Business Name): MR. JONATHAN JOSEPH BLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 AIRPORT BLVD
BURLINGAME CA
94010-1908
US

IV. Provider business mailing address

700 AIRPORT BLVD STE 490&495
BURLINGAME CA
94010-1908
US

V. Phone/Fax

Practice location:
  • Phone: 650-517-8220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberJONB22
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: