Provider Demographics
NPI:1396967345
Name:BRADLEY, JACK EMERY (DC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:EMERY
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 N UNCOMPAHGRE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401
Mailing Address - Country:US
Mailing Address - Phone:970-252-8255
Mailing Address - Fax:970-252-9280
Practice Address - Street 1:101 N UNCOMPAHGRE
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-252-8255
Practice Address - Fax:970-252-9280
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR3842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO800840OtherGROUP NUMBER
CO800841Medicare PIN