Basic Information
| Provider Information | |||||||||
| NPI: | 1871110221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | LARISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT STREET | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137945700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 42 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133705285 | ||||||||
| FaxNumber: | 4133705384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2020 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | RN2328085 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.