Provider Demographics
NPI:1497361182
Name:RYBURN, JASON DALE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DALE
Last Name:RYBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:LONSDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72087-9670
Mailing Address - Country:US
Mailing Address - Phone:501-326-5679
Mailing Address - Fax:
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL051729164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse