Provider Demographics
NPI:1003328410
Name:JARVIS, BRIEANA LEE
Entity Type:Individual
Prefix:
First Name:BRIEANA
Middle Name:LEE
Last Name:JARVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 THOREAU LN
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2757
Mailing Address - Country:US
Mailing Address - Phone:937-708-0477
Mailing Address - Fax:
Practice Address - Street 1:125 THOREAU LN
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2757
Practice Address - Country:US
Practice Address - Phone:937-708-0477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0221675Medicaid