Provider Demographics
NPI:1871930149
Name:BRADLEY, JACKIE FAYE (MED)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:FAYE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7980 ANCHOR DR BLDG 500
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-8285
Mailing Address - Country:US
Mailing Address - Phone:409-727-6400
Mailing Address - Fax:409-727-6403
Practice Address - Street 1:7980 ANCHOR DR BLDG 500
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-8285
Practice Address - Country:US
Practice Address - Phone:409-727-6400
Practice Address - Fax:409-727-6403
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional