Healthcare Provider Details

I. General information

NPI: 1740834753
Provider Name (Legal Business Name): JALEESE DENEE BRYANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 SE MARLIN AVE
WARRENTON OR
97146-9624
US

IV. Provider business mailing address

65 N HIGHWAY 101 STE 204
WARRENTON OR
97146-9371
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-5722
  • Fax:
Mailing address:
  • Phone: 503-325-5722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1301180318
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: