Provider Demographics
NPI:1528369519
Name:RYAN, JESSICA MICHELLE (MSPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 SAVOY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3914
Mailing Address - Country:US
Mailing Address - Phone:619-889-0568
Mailing Address - Fax:
Practice Address - Street 1:2751 ROOSEVELT RD
Practice Address - Street 2:BUILDING 210, STE. 203
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6180
Practice Address - Country:US
Practice Address - Phone:619-795-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25981225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist