Provider Demographics
NPI:1730793456
Name:BRYANT ROLAND, JADA
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:BRYANT ROLAND
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 1:11419 LAURELWALK DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3008
Mailing Address - Country:US
Mailing Address - Phone:239-410-1040
Mailing Address - Fax:
Practice Address - Street 1:6100 DAYLONG LN STE 103
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1631
Practice Address - Country:US
Practice Address - Phone:410-531-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-20-132128106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician