Provider Demographics
NPI:1033781075
Name:BRYANT, JACQUELINE MILLER (SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MILLER
Last Name:BRYANT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SHAFTSBURY RD
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-9578
Mailing Address - Country:US
Mailing Address - Phone:252-287-9340
Mailing Address - Fax:
Practice Address - Street 1:312 ACADEMY ST S # G
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3200
Practice Address - Country:US
Practice Address - Phone:252-578-9078
Practice Address - Fax:252-276-2218
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist