Provider Demographics
NPI:1336881085
Name:BRADLEY, JODI (PTA)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 FISHHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6439
Mailing Address - Country:US
Mailing Address - Phone:912-439-0879
Mailing Address - Fax:
Practice Address - Street 1:8205 FISHHAWK AVE
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6439
Practice Address - Country:US
Practice Address - Phone:912-439-9567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30421225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant