MEDICARE: JERRI BRADSHAW PA-C

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	363A00000X	Physician Assistant	1402	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609893676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRI BRADSHAW PA-C

Provider Business Mailing Address
First Line	:	PO BOX 776084
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-6084
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16370 US HIGHWAY 70
Second Line	:
City	:	LONE GROVE
State	:	OK
Zip	:	73443-6535
Country	:	US
Telephone Number	:	580-224-2862
Fax Number	:	580-224-2863

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

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	03/13/2026

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Directions to “ JERRI BRADSHAW PA-C” Practice Location

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