Provider Demographics
NPI:1235015587
Name:BRADLEY, JENNA ALEXANDRIA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ALEXANDRIA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32375 LIGHTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SELBYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19975-3407
Mailing Address - Country:US
Mailing Address - Phone:410-713-8099
Mailing Address - Fax:
Practice Address - Street 1:32393 LIGHTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SELBYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19975-3407
Practice Address - Country:US
Practice Address - Phone:410-713-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0013318363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily