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General NPI Number Information
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NPI Number | 1871605501
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Entity Type | Individual
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Provider Name | JILL KRISTEN BRADFORD MSED, ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1800 SE TIFFANY AVE
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-7521
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Country | US
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Telephone | 772-335-4000
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Fax | 772-398-3700
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Provider Business Mailing Address
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Address Line | 1825 SW ANGELICO LN
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City | PORT ST LUCIE
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State | FL
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Zip | 34984-4456
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Country | US
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Telephone | 772-336-5296
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL1271
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License Number State | FL
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