Provider Demographics
NPI:1013170182
Name:BRADFORD, JEREMY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LYNN
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11654 MILLWIND DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-5032
Mailing Address - Country:US
Mailing Address - Phone:901-337-4316
Mailing Address - Fax:
Practice Address - Street 1:794 S COOPER ST STE 102
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5406
Practice Address - Country:US
Practice Address - Phone:901-337-4316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00881382OtherRAILROAD MEDICARE
TN3371161Medicaid
MS7187860Medicaid
TN9680169OtherAETNA
TN4189661OtherBCBS
MS620819926OtherBCBS
TN620819926OtherTRICARE
AR110318002Medicaid
MS07274094Medicaid
TN1512533Medicaid
TN620819926OtherAETNA
TN620819926OtherCIGNA
TN0723280001Medicare NSC
TN620819926OtherTRICARE