Provider Demographics
NPI:1225503691
Name:BRALEY, JENNIFER DENISE (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:BRALEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 STOCKTON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2055
Mailing Address - Country:US
Mailing Address - Phone:501-454-1795
Mailing Address - Fax:
Practice Address - Street 1:824 N TYLER ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3535
Practice Address - Country:US
Practice Address - Phone:501-664-2961
Practice Address - Fax:501-664-6208
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR070416163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory CareGroup - Multi-Specialty