MEDICARE: JESSICA NICOLE BRADFORD PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA002337	GA

General Provider Information

NPI Number	:	1811196181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA NICOLE BRADFORD PTA

Provider Business Mailing Address
First Line	:	1856 BARRINGTON CT
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-4911
Country	:	US
Telephone Number	:	404-909-7187
Fax Number	:

Provider Business Practice Location Address
First Line	:	3459 ACWORTH DUE WEST RD NW
Second Line	:	SUITE 410
City	:	ACWORTH
State	:	GA
Zip	:	30101-5819
Country	:	US
Telephone Number	:	770-974-7494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2007
Last Update Date	:	07/16/2007

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