Provider Demographics
NPI:1073291605
Name:BRADSHAW, JAYNE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:MARIE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 S REDWOOD RD STE C
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9271
Mailing Address - Country:US
Mailing Address - Phone:801-860-4325
Mailing Address - Fax:
Practice Address - Street 1:8817 S REDWOOD RD STE C
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9271
Practice Address - Country:US
Practice Address - Phone:801-860-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT349456-4701405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty