Provider Demographics
NPI:1922499565
Name:BRYANT, JEANNA MAXWELL
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:MAXWELL
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNA
Other - Middle Name:YVONNE
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2276
Mailing Address - Country:US
Mailing Address - Phone:229-377-3688
Mailing Address - Fax:229-377-2066
Practice Address - Street 1:1000 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2276
Practice Address - Country:US
Practice Address - Phone:229-377-3688
Practice Address - Fax:229-377-2066
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist