Provider Demographics
NPI:1124340351
Name:BRADDOCK, JESSICA ANN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:BRADDOCK
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 1:540 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4830
Mailing Address - Country:US
Mailing Address - Phone:904-264-2156
Mailing Address - Fax:
Practice Address - Street 1:4495 ROOSEVELT BLVD
Practice Address - Street 2:SUITE #317
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3375
Practice Address - Country:US
Practice Address - Phone:904-384-4415
Practice Address - Fax:904-384-4212
Is Sole Proprietor?:No
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21789225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant