Basic Information
| Provider Information | |||||||||
| NPI: | 1154614469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRADDOCK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 E CENTRAL AVE | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992086291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092529602 | ||||||||
| FaxNumber: | 5097899031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60644738 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 173365 | NC | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | MD60644738 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.