Provider Demographics
NPI:1922252246
Name:RYAN, JACK (LADC, LPC)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:LADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MANOR LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3214
Mailing Address - Country:US
Mailing Address - Phone:860-519-6492
Mailing Address - Fax:
Practice Address - Street 1:2475 ALBANY AVE STE 203B
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2523
Practice Address - Country:US
Practice Address - Phone:860-519-6492
Practice Address - Fax:860-519-6492
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008885101YA0400X
101YA0400X
CT003589101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)