Provider Demographics
NPI:1780316166
Name:BRADSHAW, JAYME EVELYN (LCSW)
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:EVELYN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2632
Mailing Address - Country:US
Mailing Address - Phone:815-690-7170
Mailing Address - Fax:
Practice Address - Street 1:735 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-2632
Practice Address - Country:US
Practice Address - Phone:815-690-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-25
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490148531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical