MEDICARE: JENNIE BRADACH

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	174400000X	Specialist	9504	CA

General Provider Information

NPI Number	:	1649025495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE BRADACH

Provider Business Mailing Address
First Line	:	6516 CANYON CREST DR
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-4694
Country	:	US
Telephone Number	:	858-305-0878
Fax Number	:

Provider Business Practice Location Address
First Line	:	9750 MIRAMAR RD STE 130
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92126-4561
Country	:	US
Telephone Number	:	858-305-0878
Fax Number	:

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

Provider Enumeration Date	:	04/23/2024
Last Update Date	:	04/23/2024

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Directions to “ JENNIE BRADACH ” Practice Location

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