Provider Demographics
NPI:1952799637
Name:BRADFORD, JACQUELINE (MA, MFT, NCC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MA, MFT, NCC
Other - Prefix:
Other - First Name:J.
Other - Middle Name:ILANA
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, MFT, NCC
Mailing Address - Street 1:14523 WESTLAKE DR
Mailing Address - Street 2:SUITE 23
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7700
Mailing Address - Country:US
Mailing Address - Phone:503-828-7252
Mailing Address - Fax:
Practice Address - Street 1:14523 WESTLAKE DR
Practice Address - Street 2:SUITE 23
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7700
Practice Address - Country:US
Practice Address - Phone:503-828-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3341101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health