Provider Demographics
NPI:1669907689
Name:BRYANT, JEFFREY D
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
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 1:38855 HILLS TECH DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3428
Mailing Address - Country:US
Mailing Address - Phone:248-745-4900
Mailing Address - Fax:248-377-2676
Practice Address - Street 1:1841 N. PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:248-377-2676
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089149104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802089149Medicaid