Provider Demographics
NPI:1215033741
Name:BLACKWOOD, BRADLEY JASON (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JASON
Last Name:BLACKWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 484
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:KS
Mailing Address - Zip Code:66901-0484
Mailing Address - Country:US
Mailing Address - Phone:785-243-4049
Mailing Address - Fax:785-243-4735
Practice Address - Street 1:511 CEDAR ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-2111
Practice Address - Country:US
Practice Address - Phone:785-243-4049
Practice Address - Fax:785-243-4735
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-03920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor