Provider Demographics
NPI:1023575404
Name:BRADLEY, JESSICA LATISHA (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LATISHA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 GRAND TETON AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-9002
Mailing Address - Country:US
Mailing Address - Phone:732-984-8064
Mailing Address - Fax:
Practice Address - Street 1:7 GRAND TETON AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-9002
Practice Address - Country:US
Practice Address - Phone:732-984-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05977700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker