Provider Demographics
NPI:1285854737
Name:JACKSON, BRADLEY C
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 WEST US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3014
Mailing Address - Country:US
Mailing Address - Phone:618-624-4471
Mailing Address - Fax:618-624-4496
Practice Address - Street 1:2969 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7862
Practice Address - Country:US
Practice Address - Phone:636-379-4691
Practice Address - Fax:636-379-4820
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005036116237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist