Healthcare Provider Details

I. General information

NPI: 1295234581
Provider Name (Legal Business Name): JAYSEN DOUGLAS BRANDT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE AVE
WYANDOTTE MI
48192-4668
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-7913
  • Fax:
Mailing address:
  • Phone: 800-999-5829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704271479
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: