Provider Demographics
NPI:1487076154
Name:RADLEY, JESSICA A (PMHNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:RADLEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 DAVENPORT RD
Mailing Address - Street 2:
Mailing Address - City:MOSIER
Mailing Address - State:OR
Mailing Address - Zip Code:97040-9500
Mailing Address - Country:US
Mailing Address - Phone:541-490-2590
Mailing Address - Fax:
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3213
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-9156
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201601539NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health