Provider Demographics
NPI:1831298587
Name:BLEDSOE, BETHANY PAIGE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:PAIGE
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 LYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4235
Mailing Address - Country:US
Mailing Address - Phone:731-695-1339
Mailing Address - Fax:
Practice Address - Street 1:233 OIL WELL RD
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-8014
Practice Address - Country:US
Practice Address - Phone:731-660-8467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4138245OtherBCBS - TN
TN3987481Medicaid
TN4138245OtherBCBS - TN