=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699927939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN MARIE BRADSHAW MFT, M.S., M.A., CHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2008
-----------------------------------------------------
Last Update Date | 10/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17215 STUDEBAKER RD SUITE #180
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-400-2135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3553A ATLANTIC AVE # 569
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-4515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-400-2135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC46310
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------