Provider Demographics
NPI:1710186598
Name:BRADFORD, JEANNETTE N
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:N
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 1:630 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5010
Mailing Address - Country:US
Mailing Address - Phone:310-323-6547
Mailing Address - Fax:
Practice Address - Street 1:4920 AVALON BLVD
Practice Address - Street 2:BAART
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-4004
Practice Address - Country:US
Practice Address - Phone:323-235-5035
Practice Address - Fax:323-235-2023
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156226164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse