Provider Demographics
NPI:1316296809
Name:BRYANT, JENNIFER FUQUA (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FUQUA
Last Name:BRYANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:5875 N MAJOR DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77713-9034
Practice Address - Country:US
Practice Address - Phone:409-892-2262
Practice Address - Fax:409-892-3336
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120592363L00000X
TX687943363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02601517OtherMCRR
TX1K1805OtherMEDICARE
TX331662202Medicaid