Provider Demographics
NPI:1730778440
Name:BRADLEY, JASON ZACHARY (LMT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ZACHARY
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7744 NORTHCROSS DR APT N225
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1734
Mailing Address - Country:US
Mailing Address - Phone:337-302-5499
Mailing Address - Fax:
Practice Address - Street 1:7744 NORTHCROSS DR APT N225
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1734
Practice Address - Country:US
Practice Address - Phone:337-302-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134215225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty