Provider Demographics
NPI:1407624869
Name:BRADFORD, JENNA KAITLYN
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:KAITLYN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 N STEELHEAD WAY STE 162
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8388
Mailing Address - Country:US
Mailing Address - Phone:208-323-9747
Mailing Address - Fax:208-323-9752
Practice Address - Street 1:554 N STEELHEAD WAY STE 162
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8388
Practice Address - Country:US
Practice Address - Phone:208-323-9747
Practice Address - Fax:208-323-9752
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-8840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist