Healthcare Provider Details

I. General information

NPI: 1952649477
Provider Name (Legal Business Name): JEFFREY W BLOMMEL PC,CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S EDWIN C MOSES BLVD 4TH FLOOR, NW BLDG
DAYTON OH
45417-3424
US

IV. Provider business mailing address

601 S EDWIN C MOSES BLVD 4TH FLOOR, NW BLDG
DAYTON OH
45417-3424
US

V. Phone/Fax

Practice location:
  • Phone: 937-734-8333
  • Fax: 937-734-8339
Mailing address:
  • Phone: 937-734-8333
  • Fax: 937-734-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.1100287
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.1100287
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.110594
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: