Provider Demographics
NPI:1043729189
Name:BRYANT, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
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 1:1165 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1520
Mailing Address - Country:US
Mailing Address - Phone:636-528-1919
Mailing Address - Fax:636-528-1916
Practice Address - Street 1:1165 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1520
Practice Address - Country:US
Practice Address - Phone:636-528-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021034486363LF0000X
IL209.016689363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily