Provider Demographics
NPI:1609293356
Name:BRYAN, JESSICA W (RN, BSN, MSN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:W
Last Name:BRYAN
Suffix:
Gender:F
Credentials:RN, BSN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 FIELD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RUFFIN
Mailing Address - State:SC
Mailing Address - Zip Code:29475-4144
Mailing Address - Country:US
Mailing Address - Phone:843-599-0833
Mailing Address - Fax:
Practice Address - Street 1:2111 WILSON RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-1603
Practice Address - Country:US
Practice Address - Phone:803-321-2170
Practice Address - Fax:803-321-2300
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC209620163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE17149Medicaid