Provider Demographics
NPI:1053132340
Name:BRYAN, JESSICA LINN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LINN
Last Name:BRYAN
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 1:305 E LYFORD ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-2620
Mailing Address - Country:US
Mailing Address - Phone:618-367-3422
Mailing Address - Fax:
Practice Address - Street 1:305 E LYFORD ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-2620
Practice Address - Country:US
Practice Address - Phone:618-367-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist