Provider Demographics
NPI:1275605123
Name:RYAN, JASON R (DC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:R
Last Name:RYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 DONEHOO ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2046
Mailing Address - Country:US
Mailing Address - Phone:912-489-5559
Mailing Address - Fax:912-489-3028
Practice Address - Street 1:303 DONEHOO ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2046
Practice Address - Country:US
Practice Address - Phone:912-489-5559
Practice Address - Fax:912-489-3028
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor