Provider Demographics
NPI:1093873390
Name:BRADFORD, JESSICA L (ORTL)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:ORTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 KELLER AVE SQ
Mailing Address - Street 2:
Mailing Address - City:AMERY
Mailing Address - State:WI
Mailing Address - Zip Code:54001
Mailing Address - Country:US
Mailing Address - Phone:715-268-6900
Mailing Address - Fax:715-268-6895
Practice Address - Street 1:505 KELLER AVE SQ
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001
Practice Address - Country:US
Practice Address - Phone:715-268-6900
Practice Address - Fax:715-268-6895
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4452 026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP66372OtherHEALTH PARTNERS
6406747OtherMEDICA INS
WI41037300Medicaid
530COBROtherBC BS OF MN