Provider Demographics
NPI:1114160389
Name:BRADLEY, JESSE H JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:H
Last Name:BRADLEY
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1752
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-1752
Mailing Address - Country:US
Mailing Address - Phone:870-733-0888
Mailing Address - Fax:870-733-0889
Practice Address - Street 1:116 W TYLER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-733-0888
Practice Address - Fax:870-733-0889
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-16
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80197213ES0103X
MO2007024292213ES0103X
TN695213ES0103X
AR242213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180372748Medicaid
AR199945716Medicaid
AR180310717Medicaid