Provider Demographics
NPI:1689415911
Name:BRADLEY JAY E. PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BRADLEY JAY E. PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:TEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-429-0088
Mailing Address - Street 1:11278 LOS ALAMITOS BLVD UNIT 830
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 E CHAPMAN AVE UNIT 107-C
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3132
Practice Address - Country:US
Practice Address - Phone:626-429-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty