Provider Demographics
NPI:1245479856
Name:BRADSHAW, JENNIFER LYNN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 HERITAGE DR APT 37
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-5011
Mailing Address - Country:US
Mailing Address - Phone:870-543-0804
Mailing Address - Fax:
Practice Address - Street 1:400 N ROCK ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-2228
Practice Address - Country:US
Practice Address - Phone:870-543-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#P8153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSP#P8153OtherARKANSAS BOARD OF EXAMINERS SPEECH LANGUAGE PATHOLOGY AND AUDIOLOGY
AR175020721Medicaid