Provider Demographics
NPI:1275971442
Name:BRADOF, JENNIFER M (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BRADOF
Suffix:
Gender:F
Credentials:LCSW
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 2299
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2299
Mailing Address - Country:US
Mailing Address - Phone:307-222-6040
Mailing Address - Fax:
Practice Address - Street 1:480 S CACHE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8222
Practice Address - Country:US
Practice Address - Phone:307-222-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-8371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical