MEDICARE: BRYAN ELLIOTT JESTER PHD

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	103TC0700X	Clinical Psychologist	38020	TX

General Provider Information

NPI Number	:	1275001208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN ELLIOTT JESTER PHD

Provider Business Mailing Address
First Line	:	4100 SPRING VALLEY RD STE 511
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-3678
Country	:	US
Telephone Number	:	214-586-0092
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 SPRING VALLEY RD STE 511
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-3678
Country	:	US
Telephone Number	:	214-586-0092
Fax Number	:

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

Provider Enumeration Date	:	11/07/2018
Last Update Date	:	11/07/2018

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