Provider Demographics
NPI:1235738758
Name:BRADFORD, JARED (PTA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7080 N MAPLE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8003
Mailing Address - Country:US
Mailing Address - Phone:559-326-5580
Mailing Address - Fax:
Practice Address - Street 1:7080 N MAPLE AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8003
Practice Address - Country:US
Practice Address - Phone:559-326-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant