Provider Demographics
NPI:1770628216
Name:BRYAN, JERRY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:BRYAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 GOLDEN KEY CIR
Mailing Address - Street 2:#140
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-5820
Mailing Address - Country:US
Mailing Address - Phone:915-598-9052
Mailing Address - Fax:915-598-3674
Practice Address - Street 1:1200 GOLDEN KEY CIR
Practice Address - Street 2:#140
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-5820
Practice Address - Country:US
Practice Address - Phone:915-598-9052
Practice Address - Fax:915-598-3674
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
81294PMedicare ID - Type Unspecified