Provider Demographics
NPI:1699017947
Name:BRYANT, JIMMY (CLINICALPSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:CLINICALPSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 VINE ST STE 121
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1111
Mailing Address - Country:US
Mailing Address - Phone:215-617-6510
Mailing Address - Fax:
Practice Address - Street 1:1213 VINE ST STE 121
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1111
Practice Address - Country:US
Practice Address - Phone:215-617-6510
Practice Address - Fax:866-854-7888
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA455324367172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker