Provider Demographics
NPI:1720405715
Name:JERSON, BRADLEY (PHD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:JERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RETREAT AVE
Mailing Address - Street 2:HARTFORD HOSPITAL CHILD PSYCHIATRY, DIV OF PSYCHOLOGY
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-837-5206
Mailing Address - Fax:
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9507
Practice Address - Fax:860-545-9561
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003501103T00000X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent