Basic Information
| Provider Information | |||||||||
| NPI: | 1982362448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMHC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655735567 | ||||||||
| FaxNumber: | 7657410359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2021 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 99111834A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.