=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821487182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA BRADLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2015
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2094 EE WALLACE BLVD N
-----------------------------------------------------
City | FERRIDAY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71334-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-757-8172
-----------------------------------------------------
Fax | 318-757-0762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2094 EE WALLACE BLVD N
-----------------------------------------------------
City | FERRIDAY
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71334-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-757-8172
-----------------------------------------------------
Fax | 318-757-0762
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PST.018571
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E-010421
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------