Provider Demographics
NPI:1093146250
Name:RYAN, JACOB (MS ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 LANCASTER AVENUE
Mailing Address - Street 2:115 ALUMNI COLISEUM
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-622-8174
Mailing Address - Fax:
Practice Address - Street 1:521 LANCASTER AVENUE
Practice Address - Street 2:115 ALUMNI COLISEUM
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-622-8174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT4952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer