Basic Information
| Provider Information | |||||||||
| NPI: | 1235419664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | JACLYN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 945 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317374374 | ||||||||
| FaxNumber: | 2318309196 | ||||||||
| Practice Location | |||||||||
| Address1: | 16760 LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169353300 | ||||||||
| FaxNumber: | 6169353333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501015614 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.