Basic Information
| Provider Information | |||||||||
| NPI: | 1992217574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRYSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 549 GLEN RIDGE DR S | ||||||||
| Address2: | |||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088071613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087451017 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION CT | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 12491 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.