Provider Demographics
NPI:1154614469
Name:CRADDOCK, JESSICA RENAE (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENAE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6291
Practice Address - Country:US
Practice Address - Phone:509-252-9602
Practice Address - Fax:509-789-9031
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60644738207R00000X, 2084N0400X
NC173365390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program