Provider Demographics
NPI:1619643244
Name:BRADSHAW, JENNIFER (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MARINA COVE DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4426
Mailing Address - Country:US
Mailing Address - Phone:850-582-4629
Mailing Address - Fax:
Practice Address - Street 1:100 COLLEGE BLVD E
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1347
Practice Address - Country:US
Practice Address - Phone:850-729-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL25012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer