=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467063362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA RENEE BRADLEY TCADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2020
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 STONECREST CT STE 100
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40065-8128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-437-0859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2391 SIR BARTON WAY APT 1305
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-2566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-475-4009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 247309
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------