Provider Demographics
NPI:1871605501
Name:BRADFORD, JILL KRISTEN (MSED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:KRISTEN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MSED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SW ANGELICO LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4456
Mailing Address - Country:US
Mailing Address - Phone:772-336-5296
Mailing Address - Fax:
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:772-335-4000
Practice Address - Fax:772-398-3700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer