Healthcare Provider Details

I. General information

NPI: 1861924979
Provider Name (Legal Business Name): JESSICA RENAE BRADFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 12/06/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 4TH AVE S
BIRMINGHAM AL
35233-1511
US

IV. Provider business mailing address

1400 4TH AVE S
BIRMINGHAM AL
35233-1511
US

V. Phone/Fax

Practice location:
  • Phone: 205-329-7200
  • Fax:
Mailing address:
  • Phone: 205-329-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD43175
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: