Provider Demographics
NPI:1396227823
Name:RYAN, JACQUELINE NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 FLAAM ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3571
Mailing Address - Country:US
Mailing Address - Phone:732-691-5536
Mailing Address - Fax:
Practice Address - Street 1:1372 ROUTE 9 BLDG 2
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-4038
Practice Address - Country:US
Practice Address - Phone:732-240-9296
Practice Address - Fax:732-240-9297
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01819400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist