Provider Demographics
NPI:1073053922
Name:BRADFORD, JESSICA (BS, LADC, BCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:BS, LADC, BCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 3RD ST W
Mailing Address - Street 2:BOX 254
Mailing Address - City:MANTORVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55955-8081
Mailing Address - Country:US
Mailing Address - Phone:507-272-8446
Mailing Address - Fax:
Practice Address - Street 1:610 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4704
Practice Address - Country:US
Practice Address - Phone:507-413-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304221101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)