Provider Demographics
NPI:1871517672
Name:BLOOMFIELD, JEREMY W (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:W
Last Name:BLOOMFIELD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 SHERMAN AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3753
Mailing Address - Country:US
Mailing Address - Phone:312-409-5614
Mailing Address - Fax:
Practice Address - Street 1:1609 SHERMAN AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3753
Practice Address - Country:US
Practice Address - Phone:312-409-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006685103T00000X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy