=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720586662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMERSON BRYANT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2018
-----------------------------------------------------
Last Update Date | 11/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MILITARY DR
-----------------------------------------------------
City | CHATHAM
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24531-4683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-944-4126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 370 HUNTERS MILL LN
-----------------------------------------------------
City | EVINGTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24550-4281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-944-4126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019012885
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 0126003030
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------