Provider Demographics
NPI:1427181411
Name:BRADDOCK, JESSICA ROSE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WILDWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2673
Mailing Address - Country:US
Mailing Address - Phone:601-498-5591
Mailing Address - Fax:
Practice Address - Street 1:23 MASON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4437
Practice Address - Country:US
Practice Address - Phone:601-399-0539
Practice Address - Fax:601-399-1617
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist