Provider Demographics
NPI:1497162564
Name:BRYAN, JENNIFER A (PTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 MANZANO CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-7701
Mailing Address - Country:US
Mailing Address - Phone:903-522-2247
Mailing Address - Fax:
Practice Address - Street 1:302 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-5303
Practice Address - Country:US
Practice Address - Phone:979-821-9478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2104693225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant