Provider Demographics
NPI:1144578857
Name:BRACERO, JESSICA
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:BRACERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 HAMILTON CIR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3822
Mailing Address - Country:US
Mailing Address - Phone:518-569-0283
Mailing Address - Fax:
Practice Address - Street 1:52 HAMILTON CIR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3822
Practice Address - Country:US
Practice Address - Phone:518-569-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1355760235Z00000X
PASL011855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist