Provider Demographics
NPI:1558430785
Name:BRADDOCK, JENNY M (PT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:M
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 HILL RD
Mailing Address - Street 2:
Mailing Address - City:HARWINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06791-2502
Mailing Address - Country:US
Mailing Address - Phone:860-485-0755
Mailing Address - Fax:
Practice Address - Street 1:117 SHARON RD
Practice Address - Street 2:MALL VIEW PLAZA
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-4000
Practice Address - Country:US
Practice Address - Phone:203-756-2334
Practice Address - Fax:203-756-2594
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007053174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080007053CT01OtherBCBS PROVIDER NUMBER
CT076582Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER