Healthcare Provider Details

I. General information

NPI: 1386004075
Provider Name (Legal Business Name): JANE BLOOM PHDRNCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 GOLDEN HILL
LEE MA
01238-9132
US

IV. Provider business mailing address

95 GOLDEN HILL
LEE MA
01238-9132
US

V. Phone/Fax

Practice location:
  • Phone: 413-243-3336
  • Fax:
Mailing address:
  • Phone: 413-243-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN100531
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: