MEDICARE: JEREMY ALLEN BRYANT LCMHC

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	101YM0800X	Mental Health Counselor	10166	NC

General Provider Information

NPI Number	:	1790457745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY ALLEN BRYANT LCMHC

Provider Business Mailing Address
First Line	:	318 FIELDSTONE DR
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215-4639
Country	:	US
Telephone Number	:	336-416-4096
Fax Number	:

Provider Business Practice Location Address
First Line	:	318 FIELDSTONE DR
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215-4639
Country	:	US
Telephone Number	:	336-416-4096
Fax Number	:

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

Provider Enumeration Date	:	09/29/2021
Last Update Date	:	09/29/2021

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