Basic Information
| Provider Information | |||||||||
| NPI: | 1295988319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYSON | ||||||||
| FirstName: | JARED | ||||||||
| MiddleName: | |||||||||
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| Credential: | IMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31681 RIVERSIDE DR | ||||||||
| Address2: | SUITE L | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925307815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | 9516749635 | ||||||||
| Practice Location | |||||||||
| Address1: | 31681 RIVERSIDE DR | ||||||||
| Address2: | SUITE L | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925307815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516749243 | ||||||||
| FaxNumber: | 9516749635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2008 | ||||||||
| LastUpdateDate: | 11/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 56726 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.