Provider Demographics
NPI:1013296177
Name:BRADSHAW, JACOB ALEXANDER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 COLUMBIA CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-6149
Mailing Address - Country:US
Mailing Address - Phone:405-240-7003
Mailing Address - Fax:
Practice Address - Street 1:1104 COLUMBIA COURT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003
Practice Address - Country:US
Practice Address - Phone:405-240-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst