Provider Demographics
NPI:1508126673
Name:RYAN, JESSICA SUZANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:SUZANNE
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22011 STATE HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-8745
Mailing Address - Country:US
Mailing Address - Phone:251-509-5100
Mailing Address - Fax:
Practice Address - Street 1:22011 STATE HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-8745
Practice Address - Country:US
Practice Address - Phone:251-509-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health