Healthcare Provider Details

I. General information

NPI: 1467063362
Provider Name (Legal Business Name): JESSICA RENEE BRADLEY TCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 STONECREST CT STE 100
SHELBYVILLE KY
40065-8128
US

IV. Provider business mailing address

2391 SIR BARTON WAY APT 1305
LEXINGTON KY
40509-2566
US

V. Phone/Fax

Practice location:
  • Phone: 502-437-0859
  • Fax:
Mailing address:
  • Phone: 859-475-4009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number247309
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: