Provider Demographics
NPI:1730179094
Name:BRYANT, JILL KATHLEEN (PHD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:KATHLEEN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 7TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-3450
Mailing Address - Country:US
Mailing Address - Phone:319-531-1149
Mailing Address - Fax:319-538-0278
Practice Address - Street 1:1375 7TH AVE STE D
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-3450
Practice Address - Country:US
Practice Address - Phone:319-531-1149
Practice Address - Fax:319-538-0278
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00984101YM0800X
IA212071101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4720Medicaid
IA4720Medicaid