Provider Demographics
NPI:1073868261
Name:BRADFORD, JENNIFER THERESE (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:THERESE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10366 BARRINGTON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-6767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10623 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3433
Practice Address - Country:US
Practice Address - Phone:703-361-7131
Practice Address - Fax:703-330-2065
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10042728208000000X
VA0102203986208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics