Provider Demographics
NPI:1750994893
Name:BRADFORD, JEREMIE
Entity type:Individual
Prefix:
First Name:JEREMIE
Middle Name:
Last Name:BRADFORD
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 1:9450 W HACIENDA AVE UNIT 108
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7721
Mailing Address - Country:US
Mailing Address - Phone:702-984-0190
Mailing Address - Fax:
Practice Address - Street 1:5412 BOULDER HWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6039
Practice Address - Country:US
Practice Address - Phone:702-291-7121
Practice Address - Fax:702-947-6335
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst