Provider Demographics
NPI:1114091048
Name:RYAN, JESSICA L (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 ELMWOOD AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1666
Mailing Address - Country:US
Mailing Address - Phone:716-871-9883
Mailing Address - Fax:
Practice Address - Street 1:2565 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1939
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58 016089235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist