Provider Demographics
NPI:1558844696
Name:BRADLEY, JILL (PTA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-5020
Mailing Address - Country:US
Mailing Address - Phone:434-222-6301
Mailing Address - Fax:
Practice Address - Street 1:2244 ASHLEY CROSSING DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5700
Practice Address - Country:US
Practice Address - Phone:434-222-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3400225200000X
VA2306603186225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant