Provider Demographics
NPI:1598359903
Name:BRYANT, JACOB HAROLD (LCSW)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:HAROLD
Last Name:BRYANT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 BISCAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2011
Mailing Address - Country:US
Mailing Address - Phone:386-310-9662
Mailing Address - Fax:
Practice Address - Street 1:1737 BISCAYNE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2011
Practice Address - Country:US
Practice Address - Phone:386-310-9662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL124581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12458OtherSOCIAL WORK LICENSE