Healthcare Provider Details

I. General information

NPI: 1578870119
Provider Name (Legal Business Name): JEFFREY MICHAEL BRYANT MARRIAGE AND FAMILY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

IV. Provider business mailing address

443 FRANCIS RD
BONNE TERRE MO
63628-3711
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-5353
  • Fax:
Mailing address:
  • Phone: 775-870-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2023032927
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: