Provider Demographics
NPI:1578234191
Name:BRADAC, JENNIFER (OT/L, LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRADAC
Suffix:
Gender:F
Credentials:OT/L, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4391
Mailing Address - Country:US
Mailing Address - Phone:440-942-4358
Mailing Address - Fax:
Practice Address - Street 1:4950 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4391
Practice Address - Country:US
Practice Address - Phone:440-942-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT005217225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty