Provider Demographics
NPI:1174071963
Name:JENNIFER K BRADLEY, PSYD LLC
Entity type:Organization
Organization Name:JENNIFER K BRADLEY, PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:480-917-3255
Mailing Address - Street 1:4500 S LAKESHORE DR
Mailing Address - Street 2:STE 345
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-7052
Mailing Address - Country:US
Mailing Address - Phone:480-917-3255
Mailing Address - Fax:480-838-9022
Practice Address - Street 1:4500 S LAKESHORE DR
Practice Address - Street 2:STE 345
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7052
Practice Address - Country:US
Practice Address - Phone:480-917-3255
Practice Address - Fax:480-838-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3451103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ119075Medicare PIN