Healthcare Provider Details

I. General information

NPI: 1174669543
Provider Name (Legal Business Name): JANE C. BRYANT MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

1333 IRIS AVE.
BOULDER CO
80304
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax:
Mailing address:
  • Phone: 303-443-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2369
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2369
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerLPC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: