Provider Demographics
NPI:1083862197
Name:RYAN, JENNIFER LYNN (MS, LADC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LADC, CCDP-D
Mailing Address - Street 1:30 CONTROLS DRIVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5434
Mailing Address - Country:US
Mailing Address - Phone:475-675-2981
Mailing Address - Fax:475-675-2982
Practice Address - Street 1:30 CONTROLS DRIVE
Practice Address - Street 2:SUITE 10
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-5434
Practice Address - Country:US
Practice Address - Phone:475-675-2981
Practice Address - Fax:475-675-2982
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001059101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)