Provider Demographics
NPI:1851638340
Name:BRADFORD, JACQUE L (PT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUE
Middle Name:L
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 MADISON AVE
Mailing Address - Street 2:DEPARTMENT OF PHYSICAL THERAPY
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3410
Mailing Address - Country:US
Mailing Address - Phone:901-448-5888
Mailing Address - Fax:901-448-1411
Practice Address - Street 1:930 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3410
Practice Address - Country:US
Practice Address - Phone:901-448-5888
Practice Address - Fax:901-448-1411
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2016-02-18
Deactivation Date:2014-11-04
Deactivation Code:
Reactivation Date:2016-01-25
Provider Licenses
StateLicense IDTaxonomies
TN8431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist