1578037784 NPI number — MRS. JESSICA MARIE BRADLEY FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578037784 NPI number — MRS. JESSICA MARIE BRADLEY FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
JESSICA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOJA
Provider Other First Name:
JESSICA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578037784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 S. STATE STREET
Provider Second Line Business Mailing Address:
MAIL CODE 3055
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19901-3530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-480-1688
Provider Business Mailing Address Fax Number:
302-480-9807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WELLNESS WAY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19963-4366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-503-2460
Provider Business Practice Location Address Fax Number:
302-424-9162
Provider Enumeration Date:
01/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  LG-0001209 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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