MEDICARE: JADE BRYANT FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0992962	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154861995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADE BRYANT FNP-BC

Provider Business Mailing Address
First Line	:	19 E ABARR DR # 200
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81007-5436
Country	:	US
Telephone Number	:	719-582-1489
Fax Number	:	719-434-9807

Provider Business Practice Location Address
First Line	:	1910 LAKE AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81004-3322
Country	:	US
Telephone Number	:	719-582-1489
Fax Number	:	719-434-9807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2017
Last Update Date	:	03/04/2024

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