MEDICARE: JACQUELINE RENEE BRYANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker

General Provider Information

NPI Number	:	1265192397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE RENEE BRYANT

Provider Business Mailing Address
First Line	:	1916 VIVIAN ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-2234
Country	:	US
Telephone Number	:	318-946-0146
Fax Number	:

Provider Business Practice Location Address
First Line	:	1916 VIVIAN ST
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71108-2234
Country	:	US
Telephone Number	:	318-946-0146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2021
Last Update Date	:	12/30/2021

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Directions to “ JACQUELINE RENEE BRYANT ” Practice Location

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