Healthcare Provider Details

I. General information

NPI: 1437582681
Provider Name (Legal Business Name): JENNA NICOLE BRADLEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 VISTA WAY SUITE 101
OCEANSIDE CA
92056-4568
US

IV. Provider business mailing address

3633 VISTA WAY SUITE 101
OCEANSIDE CA
92056-4568
US

V. Phone/Fax

Practice location:
  • Phone: 760-729-7298
  • Fax: 760-729-7206
Mailing address:
  • Phone: 760-729-7298
  • Fax: 760-729-7206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT40258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: