Provider Demographics
NPI:1962260190
Name:BRADLEY, LATASHA LASHAE
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:LASHAE
Last Name:BRADLEY
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 1:341 EDGEWOOD TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-6217
Mailing Address - Country:US
Mailing Address - Phone:601-486-7344
Mailing Address - Fax:
Practice Address - Street 1:341 EDGEWOOD TERRACE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-6217
Practice Address - Country:US
Practice Address - Phone:601-486-7344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator