Provider Demographics
NPI:1073843199
Name:BRADLEY, JESIKA LIN (BA)
Entity Type:Individual
Prefix:
First Name:JESIKA
Middle Name:LIN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 H ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1045
Mailing Address - Country:US
Mailing Address - Phone:707-444-0641
Mailing Address - Fax:707-268-8269
Practice Address - Street 1:555 H ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1045
Practice Address - Country:US
Practice Address - Phone:707-444-0641
Practice Address - Fax:707-268-8269
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA946000513171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator