Healthcare Provider Details

I. General information

NPI: 1285854737
Provider Name (Legal Business Name): BRADLEY C JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2969 HIGHWAY K
O FALLON MO
63368-7862
US

IV. Provider business mailing address

1415 WEST US HIGHWAY 50
O FALLON IL
62269-3014
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-4691
  • Fax: 636-379-4820
Mailing address:
  • Phone: 618-624-4471
  • Fax: 618-624-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2005036116
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: