Provider Demographics
NPI:1144972423
Name:BRADSHHAW, JORDYN SUHRA
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:SUHRA
Last Name:BRADSHHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120S COUNTY ROAD 442
Mailing Address - Street 2:
Mailing Address - City:COOKS
Mailing Address - State:MI
Mailing Address - Zip Code:49817-9726
Mailing Address - Country:US
Mailing Address - Phone:616-456-6571
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE BLDG B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6851116889104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor