Provider Demographics
NPI:1992581433
Name:BLEDSOE, NAKEISHA (SUCRC)
Entity type:Individual
Prefix:
First Name:NAKEISHA
Middle Name:
Last Name:BLEDSOE
Suffix:
Gender:F
Credentials:SUCRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24811 WOODACRE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-1717
Mailing Address - Country:US
Mailing Address - Phone:510-274-3391
Mailing Address - Fax:
Practice Address - Street 1:107 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1948
Practice Address - Country:US
Practice Address - Phone:510-886-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)