Provider Demographics
NPI:1659903326
Name:RYAN, JAKE (MS, AMFT)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:MS, AMFT
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:REINAGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 911085
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-1085
Mailing Address - Country:US
Mailing Address - Phone:858-373-7139
Mailing Address - Fax:
Practice Address - Street 1:3914 MURPHY CANYON RD STE A201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4423
Practice Address - Country:US
Practice Address - Phone:858-373-7139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115800106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist