Provider Demographics
NPI:1598791550
Name:BRADBURN, JOCELYN
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:
Last Name:BRADBURN
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 1:710 BARROCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8596
Mailing Address - Country:US
Mailing Address - Phone:336-751-5636
Mailing Address - Fax:
Practice Address - Street 1:119 W DEPOT ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2327
Practice Address - Country:US
Practice Address - Phone:336-751-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC718101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102958Medicaid