Provider Demographics
NPI:1730906595
Name:BRADLEY, JENNIFER G (CCC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7826 PAMALANE CT
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-6264
Mailing Address - Country:US
Mailing Address - Phone:734-775-5662
Mailing Address - Fax:
Practice Address - Street 1:7826 PAMALANE CT
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-6264
Practice Address - Country:US
Practice Address - Phone:734-775-5662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist