Provider Demographics
NPI:1720586662
Name:BRYANT, JAMERSON
Entity Type:Individual
Prefix:
First Name:JAMERSON
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 HUNTERS MILL LN
Mailing Address - Street 2:
Mailing Address - City:EVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24550-4281
Mailing Address - Country:US
Mailing Address - Phone:434-944-4126
Mailing Address - Fax:
Practice Address - Street 1:200 MILITARY DR
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:VA
Practice Address - Zip Code:24531-4683
Practice Address - Country:US
Practice Address - Phone:434-944-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012885225700000X
VA01260030302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty