Provider Demographics
NPI:1669073359
Name:BENNETT-BRADSHAW, JODI
Entity type:Individual
Prefix:MS
First Name:JODI
Middle Name:
Last Name:BENNETT-BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 PONDFIELD CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9145
Mailing Address - Country:US
Mailing Address - Phone:336-420-0443
Mailing Address - Fax:
Practice Address - Street 1:418B W MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2534
Practice Address - Country:US
Practice Address - Phone:704-780-4271
Practice Address - Fax:704-788-2016
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11991928OtherDRIVERS LICENSE