Basic Information
| Provider Information | |||||||||
| NPI: | 1285244129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | JENNA | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2658 GALE CT APT 4 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9378758706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326081135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523761611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 14299150 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.