Provider Demographics
NPI:1164922829
Name:BRADHAM, JESSICA NICOLE (LPA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:BRADHAM
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 OLIVEPARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-6224
Mailing Address - Country:US
Mailing Address - Phone:513-407-2442
Mailing Address - Fax:
Practice Address - Street 1:7406 CHAPEL HILL RD STE GH
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-5077
Practice Address - Country:US
Practice Address - Phone:919-346-3204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5032103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool