Provider Demographics
NPI:1124638010
Name:BLOSSOM, JENNAH KAY MARIE (MC61053752)
Entity type:Individual
Prefix:
First Name:JENNAH KAY
Middle Name:MARIE
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:MC61053752
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 S MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6142
Mailing Address - Country:US
Mailing Address - Phone:406-579-8190
Mailing Address - Fax:
Practice Address - Street 1:1101 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2010
Practice Address - Country:US
Practice Address - Phone:509-324-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61053752101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health