Provider Demographics
NPI:1013377225
Name:WHITLOCK, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WHITLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 TURMAN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8998
Mailing Address - Country:US
Mailing Address - Phone:870-819-0249
Mailing Address - Fax:
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-933-9528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator