Provider Demographics
NPI:1083216410
Name:BRADLEY, JESSICA ROSE (LMSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14587 VENESSA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-6367
Mailing Address - Country:US
Mailing Address - Phone:616-610-4044
Mailing Address - Fax:
Practice Address - Street 1:665 136TH AVE STE 60
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1897
Practice Address - Country:US
Practice Address - Phone:616-205-9759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
68011079041041C0700X
MI68011079041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical