Provider Demographics
NPI:1124372321
Name:JOHNSON-BRYANT, JACQUELINE PATRICIA (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PATRICIA
Last Name:JOHNSON-BRYANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14142 MINNIEVILLE RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-2371
Mailing Address - Country:US
Mailing Address - Phone:877-489-1538
Mailing Address - Fax:877-637-4630
Practice Address - Street 1:14142 MINNIEVILLE RD
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2371
Practice Address - Country:US
Practice Address - Phone:877-489-1538
Practice Address - Fax:877-637-4630
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001136456163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA497686Medicare Oscar/Certification