Provider Demographics
NPI:1740834753
Name:BRYANT, JALEESE DENEE
Entity type:Individual
Prefix:
First Name:JALEESE
Middle Name:DENEE
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 101 STE 204
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:OR
Mailing Address - Zip Code:97146-9371
Mailing Address - Country:US
Mailing Address - Phone:503-325-5722
Mailing Address - Fax:
Practice Address - Street 1:326 SE MARLIN AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9624
Practice Address - Country:US
Practice Address - Phone:503-325-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 175T00000X, 171M00000X
CAR1301180318101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist