Provider Demographics
NPI:1043775109
Name:JIBSON, RYAN (MSW)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JIBSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9809 VALLEY PINES DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-1933
Mailing Address - Country:US
Mailing Address - Phone:916-990-7131
Mailing Address - Fax:
Practice Address - Street 1:420 FOLSOM RD STE D
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2767
Practice Address - Country:US
Practice Address - Phone:916-990-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81767106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health