Provider Demographics
NPI:1477034569
Name:BRADLEY, JACQUELINE (DPT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 KENSINGTON CIR APT 202
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-2975
Mailing Address - Country:US
Mailing Address - Phone:309-678-9928
Mailing Address - Fax:
Practice Address - Street 1:1725 S NAPERVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5855
Practice Address - Country:US
Practice Address - Phone:630-509-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0226002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics