Provider Demographics
NPI:1679226781
Name:BRADSHAW, JAMALL BRION
Entity Type:Individual
Prefix:
First Name:JAMALL
Middle Name:BRION
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25975 ZORRA LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-4114
Mailing Address - Country:US
Mailing Address - Phone:951-522-9084
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2628
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst