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General NPI Number Information
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NPI Number | 1922572262
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Entity Type | Individual
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Provider Name | JESSICA LAUREN BRADWAY LPC, ATR, LMT
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Gender | Female
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Dates
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Enumeration Date | 01/21/2019
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Last Update Date | 01/21/2019
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Provider Practice Location Address
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Address Line | 2230 S KINNICKINNIC AVE
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City | MILWAUKEE
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State | WI
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Zip | 53207-1330
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Country | US
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Telephone | 414-758-4643
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Fax |
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Provider Business Mailing Address
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Address Line | 2249 S WOODWARD ST
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City | MILWAUKEE
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State | WI
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Zip | 53207-1315
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Country | US
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Telephone | 414-758-4643
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 6563-125
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License Number State | WI
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