Healthcare Provider Details

I. General information

NPI: 1699411892
Provider Name (Legal Business Name): JESSICA BRADFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 MAIN ST
MINNEOLA KS
67865-8511
US

IV. Provider business mailing address

1006 N WHITFIELD ST
WICHITA KS
67206-1352
US

V. Phone/Fax

Practice location:
  • Phone: 620-255-2917
  • Fax:
Mailing address:
  • Phone: 620-255-2917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15-02666
License Number StateKS
# 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: