Healthcare Provider Details

I. General information

NPI: 1730090168
Provider Name (Legal Business Name): KERRY BLUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KERRY ANNE JACOBOWITZ

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N HAYNE ST APT 100
MONROE NC
28112-4883
US

IV. Provider business mailing address

5558 BRADDOCK MILL WAY
LANCASTER SC
29720-0279
US

V. Phone/Fax

Practice location:
  • Phone: 980-313-4901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number0375
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: