Healthcare Provider Details

I. General information

NPI: 1558298331
Provider Name (Legal Business Name): JESSICA BRADLEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6926 BROCKTON AVE STE 11
RIVERSIDE CA
92506-3804
US

IV. Provider business mailing address

148 TAMARISK ST
REDLANDS CA
92373-5552
US

V. Phone/Fax

Practice location:
  • Phone: 951-779-1670
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: