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 STE 5
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7785
Mailing Address - Country:US
Mailing Address - Phone:971-403-0990
Mailing Address - Fax:
Practice Address - Street 1:14523 WESTLAKE DR STE 5
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7785
Practice Address - Country:US
Practice Address - Phone:971-403-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3341101YM0800X, 101YP2500X
ORC5272101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional