Healthcare Provider Details

I. General information

NPI: 1073868261
Provider Name (Legal Business Name): JENNIFER THERESE BRADFORD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10623 CRESTWOOD DR
MANASSAS VA
20109-3433
US

IV. Provider business mailing address

10366 BARRINGTON PARK CIR
MANASSAS VA
20110-6767
US

V. Phone/Fax

Practice location:
  • Phone: 703-361-7131
  • Fax: 703-330-2065
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10042728
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102203986
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: