MEDICARE: JESSICA BRADDOCK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	MC15861	ME
2	1041C0700X	Clinical Social Worker	LC17146	ME

General Provider Information

NPI Number	:	1477919561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BRADDOCK LCSW

Provider Business Mailing Address
First Line	:	330 CAPE JELLISON RD
Second Line	:
City	:	STOCKTON SPRINGS
State	:	ME
Zip	:	04981-4726
Country	:	US
Telephone Number	:	207-322-9987
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 CAPE JELLISON RD
Second Line	:
City	:	STOCKTON SPRINGS
State	:	ME
Zip	:	04981-4726
Country	:	US
Telephone Number	:	207-322-9987
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2016
Last Update Date	:	08/06/2025

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