Provider Demographics
NPI:1669816831
Name:BRADSHAW, JACLYNN N (APN)
Entity type:Individual
Prefix:
First Name:JACLYNN
Middle Name:N
Last Name:BRADSHAW
Suffix:
Gender:
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741515
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1515
Mailing Address - Country:US
Mailing Address - Phone:206-341-3009
Mailing Address - Fax:206-753-5177
Practice Address - Street 1:925 SENECA ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2742
Practice Address - Country:US
Practice Address - Phone:206-341-3009
Practice Address - Fax:206-753-5177
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17563363L00000X
WAAP60691550363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN17563OtherLICENSE
WA2067062Medicaid