Provider Demographics
NPI:1407391055
Name:BRADSHAW, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-259-1600
Mailing Address - Fax:901-259-1698
Practice Address - Street 1:6286 BRIARCREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4023
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-259-1698
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3221363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical