Provider Demographics
NPI:1669816831
Name:BRADSHAW, JACLYNN N (APN)
Entity Type:Individual
Prefix:
First Name:JACLYNN
Middle Name:N
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2623
Mailing Address - Country:US
Mailing Address - Phone:360-782-6000
Mailing Address - Fax:
Practice Address - Street 1:2709 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2623
Practice Address - Country:US
Practice Address - Phone:360-782-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17563363L00000X
WAAP60691550363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17563OtherLICENSE
WA2067062Medicaid