Provider Demographics
NPI:1417547522
Name:BRAGG, JESSICA LYNN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BRAGG
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5131
Mailing Address - Country:US
Mailing Address - Phone:325-481-2257
Mailing Address - Fax:325-481-2023
Practice Address - Street 1:2237 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5131
Practice Address - Country:US
Practice Address - Phone:325-481-2257
Practice Address - Fax:325-481-2023
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT8150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist