Provider Demographics
NPI:1003401795
Name:BRYANT, JESSIE LEE
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:LEE
Last Name:BRYANT
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 1:2018 S TWILIGHT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5474
Mailing Address - Country:US
Mailing Address - Phone:330-475-5790
Mailing Address - Fax:
Practice Address - Street 1:7301 HANOVER GREEN DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-1765
Practice Address - Country:US
Practice Address - Phone:804-874-9929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health