Provider Demographics
NPI:1689342313
Name:WRIGHT-JORDAN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WRIGHT-JORDAN
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 1:719 TEAL ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-2333
Mailing Address - Country:US
Mailing Address - Phone:317-680-6075
Mailing Address - Fax:
Practice Address - Street 1:3171 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4784
Practice Address - Country:US
Practice Address - Phone:317-880-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN133472Medicaid