Basic Information
| Provider Information | |||||||||
| NPI: | 1669816831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | JACLYNN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2709 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607826000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2709 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983102623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607826000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 17563 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | AP60691550 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 17563 | 01 | TN | LICENSE | OTHER | 2067062 | 05 | WA | MEDICAID |