Basic Information
| Provider Information | |||||||||
| NPI: | 1386753069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8713 ARMAGH CT | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956241705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163940800 | ||||||||
| FaxNumber: | 9164297824 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 FRANKLIN BLVD | ||||||||
| Address2: | # 200 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958231820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163940800 | ||||||||
| FaxNumber: | 9164297824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 277137 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.