Provider Demographics
NPI:1669291506
Name:JEZAK, BRANTLEY SCOTT (RN)
Entity type:Individual
Prefix:
First Name:BRANTLEY
Middle Name:SCOTT
Last Name:JEZAK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8883 MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3917
Mailing Address - Country:US
Mailing Address - Phone:248-505-4293
Mailing Address - Fax:
Practice Address - Street 1:9315 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-450-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305907163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse