Provider Demographics
NPI:1225164841
Name:BRYAN, JOLI BAGOT (OT)
Entity Type:Individual
Prefix:
First Name:JOLI
Middle Name:BAGOT
Last Name:BRYAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98509
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-9509
Mailing Address - Country:US
Mailing Address - Phone:225-769-2200
Mailing Address - Fax:225-768-2185
Practice Address - Street 1:10101 PARK ROWE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1685
Practice Address - Country:US
Practice Address - Phone:225-769-2200
Practice Address - Fax:225-768-2185
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTA.Z20260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A1837545Medicare PIN