Provider Demographics
NPI:1275001208
Name:JESTER, BRYAN ELLIOTT (PHD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ELLIOTT
Last Name:JESTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SPRING VALLEY RD STE 511
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3678
Mailing Address - Country:US
Mailing Address - Phone:214-586-0092
Mailing Address - Fax:
Practice Address - Street 1:4100 SPRING VALLEY RD STE 511
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-3678
Practice Address - Country:US
Practice Address - Phone:214-586-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38020103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical