Provider Demographics
NPI:1407339260
Name:BRADSHAW, JESSICA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 S 100 E
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1303
Mailing Address - Country:US
Mailing Address - Phone:208-715-5595
Mailing Address - Fax:
Practice Address - Street 1:777 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1165
Practice Address - Country:US
Practice Address - Phone:435-283-8194
Practice Address - Fax:435-283-8205
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7243183500000X
UT6374787-8911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist