Provider Demographics
NPI:1811547565
Name:BRYAN, JESSICA (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 STARK RD
Mailing Address - Street 2:
Mailing Address - City:SARVER
Mailing Address - State:PA
Mailing Address - Zip Code:16055-8919
Mailing Address - Country:US
Mailing Address - Phone:608-572-1712
Mailing Address - Fax:
Practice Address - Street 1:224 STARK RD
Practice Address - Street 2:
Practice Address - City:SARVER
Practice Address - State:PA
Practice Address - Zip Code:16055-8919
Practice Address - Country:US
Practice Address - Phone:608-572-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered