Healthcare Provider Details

I. General information

NPI: 1558560474
Provider Name (Legal Business Name): JANE K BRYANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 GALLAHER RD
KINGSTON TN
37763-4721
US

IV. Provider business mailing address

187 GALLAHER RD
KINGSTON TN
37763-4721
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-4620
  • Fax: 865-376-1759
Mailing address:
  • Phone: 865-376-4620
  • Fax: 865-376-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number77
License Number StateTN

VIII. Authorized Official

Name: MRS. JANE KITTRELL BRYANT
Title or Position: OTR/SOLE PROPRIETOR
Credential: OCCUPATIONAL THERAPY
Phone: 865-376-4620