Healthcare Provider Details

I. General information

NPI: 1952028698
Provider Name (Legal Business Name): JESSICA BRADBURY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 TURKEY LAKE RD STE 114
ORLANDO FL
32819-4205
US

IV. Provider business mailing address

6000 TURKEY LAKE RD STE 114
ORLANDO FL
32819-4205
US

V. Phone/Fax

Practice location:
  • Phone: 321-732-3723
  • Fax: 321-352-7168
Mailing address:
  • Phone: 321-732-3723
  • Fax: 321-352-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-239504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: