Provider Demographics
NPI:1154861995
Name:BRYANT, JADE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 E ABARR DR # 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5436
Mailing Address - Country:US
Mailing Address - Phone:719-582-1489
Mailing Address - Fax:719-434-9807
Practice Address - Street 1:1910 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3322
Practice Address - Country:US
Practice Address - Phone:719-582-1489
Practice Address - Fax:719-434-9807
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-27
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0992962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000150045Medicaid