Provider Demographics
NPI:1841579752
Name:RYAN, JORDAN LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LEIGH
Last Name:RYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST # 305
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:
Practice Address - Street 1:4811 S 76TH ST # 305
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:414-325-7741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129512-121104100000X
WI9061-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker