Basic Information
| Provider Information | |||||||||
| NPI: | 1376619080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYAN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | MOTR L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 828 E 350 S | ||||||||
| Address2: | |||||||||
| City: | BRIGHAM CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357305860 | ||||||||
| FaxNumber: | 4357238781 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 S 200 W | ||||||||
| Address2: | |||||||||
| City: | BRIGHAM CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357235289 | ||||||||
| FaxNumber: | 4357230579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.