Provider Demographics
NPI:1790068526
Name:BRADSHAW, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4850
Mailing Address - Fax:601-200-4838
Practice Address - Street 1:970 LAKELAND DR STE 40
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4640
Practice Address - Country:US
Practice Address - Phone:601-200-4850
Practice Address - Fax:601-200-4838
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA0181231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist