Provider Demographics
NPI:1134674047
Name:BRYANT, JAZZ JANNIE (MHP)
Entity Type:Individual
Prefix:
First Name:JAZZ
Middle Name:JANNIE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-8382
Mailing Address - Country:US
Mailing Address - Phone:318-450-8361
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL
Practice Address - Street 2:SUITE 139
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-220-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1003279654Medicaid