Provider Demographics
NPI:1417438391
Name:RYSER-OATMAN, JONATHAN TODD (PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TODD
Last Name:RYSER-OATMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 STONE AVE APT B
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2671
Mailing Address - Country:US
Mailing Address - Phone:669-300-9412
Mailing Address - Fax:
Practice Address - Street 1:989 GOVERNORS LN STE 140
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1174
Practice Address - Country:US
Practice Address - Phone:859-494-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278568103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid