Provider Demographics
NPI:1194101402
Name:BRADLEY, JENNIFER (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7815 3RD ST N STE 203
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5443
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:
Practice Address - Street 1:3200 LABORE RD STE 102
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-5189
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10064OtherMN BOARD OF PT