Healthcare Provider Details

I. General information

NPI: 1043491251
Provider Name (Legal Business Name): JENNIFER JONAE BRADDOCK CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

11115 ETTRICK ST
OAKLAND CA
94605-5529
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-4570
  • Fax:
Mailing address:
  • Phone: 917-375-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: