Healthcare Provider Details

I. General information

NPI: 1518844547
Provider Name (Legal Business Name): JOHN ALBERT BRADSHAW JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 TRAVIS BLVD
FAIRFIELD CA
94533-4802
US

IV. Provider business mailing address

609 JEFFERSON ST
FAIRFIELD CA
94533-6293
US

V. Phone/Fax

Practice location:
  • Phone: 707-399-9190
  • Fax:
Mailing address:
  • Phone: 707-399-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: