Healthcare Provider Details

I. General information

NPI: 1144209826
Provider Name (Legal Business Name): MS. JINA VINCENT BRADFORD MCCANN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 TANNER WILLIAMS RD AVIATION TRAINING CENTER MOBILE
MOBILE AL
36608-8322
US

IV. Provider business mailing address

6348 LYNWOOD BLVD
MOUND MN
55364-1404
US

V. Phone/Fax

Practice location:
  • Phone: 251-441-6725
  • Fax: 251-441-6415
Mailing address:
  • Phone: 617-901-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number27599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: