Provider Demographics
NPI:1750659454
Name:BRADLEY, JESSIE (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 COUNTY ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:NY
Mailing Address - Zip Code:13114-4219
Mailing Address - Country:US
Mailing Address - Phone:315-591-8032
Mailing Address - Fax:315-963-4464
Practice Address - Street 1:179 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-4219
Practice Address - Country:US
Practice Address - Phone:315-591-8032
Practice Address - Fax:315-963-4464
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001813-1231H00000X
NY14000015786237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter