Basic Information
| Provider Information | |||||||||
| NPI: | 1245972710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 20TH ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257032071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1115 20TH ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257032071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046911500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1283 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.