Provider Demographics
NPI:1326098799
Name:RYAN, JACLYN M (PA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:1000 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-1132
Practice Address - Country:US
Practice Address - Phone:856-246-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00161300363A00000X
PAMA051126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P75045Medicare UPIN
PA076854Medicare ID - Type Unspecified