Provider Demographics
NPI:1073755179
Name:BRADLEY, JACOB F (OT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:F
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2071
Mailing Address - Country:US
Mailing Address - Phone:781-593-3277
Mailing Address - Fax:
Practice Address - Street 1:444 WASHINGTON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1046
Practice Address - Country:US
Practice Address - Phone:781-937-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8822225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA161216796OtherTAX ID