Provider Demographics
NPI:1821836024
Name:BRYDE, JACOB RUSSELL (DNP, AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RUSSELL
Last Name:BRYDE
Suffix:
Gender:M
Credentials:DNP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:804 SERVICE RD STE A202
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-355-2822
Mailing Address - Fax:517-355-2824
Practice Address - Street 1:804 SERVICE RD STE A110
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-2822
Practice Address - Fax:517-355-2824
Is Sole Proprietor?:No
Enumeration Date:2024-07-20
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704335991363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology