Basic Information
| Provider Information | |||||||||
| NPI: | 1669073359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT-BRADSHAW | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3902 PONDFIELD CT | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274109145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364200443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 418B W MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047804271 | ||||||||
| FaxNumber: | 7047882016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2020 | ||||||||
| LastUpdateDate: | 11/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 11991928 | 01 | NC | DRIVERS LICENSE | OTHER |