Provider Demographics
NPI:1497804207
Name:BRYAN, JENNIFER LEE (OTL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:BRYAN
Suffix:
Gender:F
Credentials:OTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2020
Mailing Address - Country:US
Mailing Address - Phone:209-368-1009
Mailing Address - Fax:209-368-1024
Practice Address - Street 1:222 W PINE ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2020
Practice Address - Country:US
Practice Address - Phone:209-368-1009
Practice Address - Fax:209-368-1024
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT3052225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00945625OtherRAILROAD MEDICARE PTAN
CAP53525Medicare UPIN
CAZZZ23038ZMedicare ID - Type UnspecifiedMEDICARE ID NUMBER