Provider Demographics
NPI:1003474362
Name:BRADWAY, JILL MARGRET
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARGRET
Last Name:BRADWAY
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 1:11099 WILDLIFE DR SE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-8824
Mailing Address - Country:US
Mailing Address - Phone:517-256-2800
Mailing Address - Fax:
Practice Address - Street 1:1095 MEDICAL PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3685
Practice Address - Country:US
Practice Address - Phone:616-588-9210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002179235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist