Provider Demographics
NPI:1376882563
Name:BRADLEY, JERRY ALLEN JR (MD, EDD, MDIV)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALLEN
Last Name:BRADLEY
Suffix:JR
Gender:M
Credentials:MD, EDD, MDIV
Other - Prefix:
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Mailing Address - Street 1:4725 SYDNEY LN LOT A
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-9681
Mailing Address - Country:US
Mailing Address - Phone:251-404-3574
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.34716207Q00000X
KY54528207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine