Provider Demographics
NPI:1710013461
Name:BRADLEY, JENNIFER ANN (SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:750 IMPERIAL ST
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-5309
Mailing Address - Country:US
Mailing Address - Phone:540-382-5114
Mailing Address - Fax:540-394-4448
Practice Address - Street 1:750 IMPERIAL ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-5309
Practice Address - Country:US
Practice Address - Phone:540-382-5114
Practice Address - Fax:540-394-4448
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12111228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist