Provider Demographics
NPI:1669188520
Name:BRADLEY, JAQUELENE VILLA
Entity type:Individual
Prefix:
First Name:JAQUELENE
Middle Name:VILLA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 VETERANS DRIVE
Mailing Address - Street 2:MAIL STOP 116A5-LD
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502
Mailing Address - Country:US
Mailing Address - Phone:859-233-4511
Mailing Address - Fax:859-281-3982
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2235
Practice Address - Country:US
Practice Address - Phone:859-233-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6084104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker