Provider Demographics
NPI:1922572262
Name:BRADWAY, JESSICA LAUREN (LPC, ATR, LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:BRADWAY
Suffix:
Gender:F
Credentials:LPC, ATR, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2249 S WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1315
Mailing Address - Country:US
Mailing Address - Phone:414-758-4643
Mailing Address - Fax:
Practice Address - Street 1:2230 S KINNICKINNIC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1330
Practice Address - Country:US
Practice Address - Phone:414-758-4643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6563-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor