Provider Demographics
NPI:1497005136
Name:RYAN, JAMAAL EMMANUEL (LSW)
Entity Type:Individual
Prefix:
First Name:JAMAAL
Middle Name:EMMANUEL
Last Name:RYAN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 RENATE DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-4952
Mailing Address - Country:US
Mailing Address - Phone:908-705-3653
Mailing Address - Fax:
Practice Address - Street 1:913 RENATE DR UNIT 3
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-4952
Practice Address - Country:US
Practice Address - Phone:908-705-3653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ44SL05958600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023701OtherAGENCY MEDICAID PROVIDER #