Provider Demographics
NPI:1265162978
Name:BRADWELL, JESSICA L (MS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BRADWELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 N 55TH LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-5840
Mailing Address - Country:US
Mailing Address - Phone:850-693-5271
Mailing Address - Fax:
Practice Address - Street 1:1310 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2803
Practice Address - Country:US
Practice Address - Phone:479-964-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health