MEDICARE: DR. JEREMY W BLOOMFIELD PSY.D.

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	103T00000X	Psychologist	071-006685	IL
2	103TC0700X	Clinical Psychologist	071-006685	IL
3	103TP2701X	Group Psychotherapy Psychologist	071-006685	IL

General Provider Information

NPI Number	:	1871517672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY W BLOOMFIELD PSY.D.

Provider Business Mailing Address
First Line	:	1609 SHERMAN AVE
Second Line	:	SUITE 302
City	:	EVANSTON
State	:	IL
Zip	:	60201-3753
Country	:	US
Telephone Number	:	312-409-5614
Fax Number	:

Provider Business Practice Location Address
First Line	:	1609 SHERMAN AVE
Second Line	:	SUITE 302
City	:	EVANSTON
State	:	IL
Zip	:	60201-3753
Country	:	US
Telephone Number	:	312-409-5614
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	02/23/2009

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