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General NPI Number Information
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NPI Number | 1053132340
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Entity Type | Individual
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Provider Name | JESSICA LINN BRYAN
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Gender | Female
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Dates
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Enumeration Date | 10/21/2024
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 305 E LYFORD ST
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City | SALEM
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State | IL
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Zip | 62881-2620
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Country | US
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Telephone | 618-367-3422
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Fax |
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Provider Business Mailing Address
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Address Line | 305 E LYFORD ST
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City | SALEM
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State | IL
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Zip | 62881-2620
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Country | US
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Telephone | 618-367-3422
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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