Provider Demographics
NPI:1275982712
Name:BRADFORD, JESSICA LEAH (MA, TLLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LEAH
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:LEAH
Other - Last Name:SYMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5620 LAKEVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6108
Practice Address - Country:US
Practice Address - Phone:248-969-9932
Practice Address - Fax:248-969-0840
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016655103T00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist