Provider Demographics
NPI:1558348607
Name:BRADBURY, JODY MARIE (OTR CHT)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:MARIE
Last Name:BRADBURY
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NE NEFF RD STE B
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6213
Mailing Address - Country:US
Mailing Address - Phone:541-330-0215
Mailing Address - Fax:541-330-0221
Practice Address - Street 1:2100 NE NEFF RD STE B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6213
Practice Address - Country:US
Practice Address - Phone:541-330-0215
Practice Address - Fax:541-330-0221
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR984275225X00000X
ID171225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298996Medicaid
386526Medicare ID - Type Unspecified