Provider Demographics
NPI:1114765757
Name:BRIGNAC, JAYLA ELIZABETH
Entity type:Individual
Prefix:
First Name:JAYLA
Middle Name:ELIZABETH
Last Name:BRIGNAC
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 1:12115 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8585
Mailing Address - Country:US
Mailing Address - Phone:678-977-4958
Mailing Address - Fax:
Practice Address - Street 1:12115 STATE AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8585
Practice Address - Country:US
Practice Address - Phone:678-977-4958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA061987681156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist