Provider Demographics
NPI:1972651552
Name:RYALL, JENNIFER DIANE (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:RYALL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DIANE
Other - Last Name:FRAGALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:212 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5939
Mailing Address - Country:US
Mailing Address - Phone:401-461-6676
Mailing Address - Fax:401-461-3165
Practice Address - Street 1:1087 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3545
Practice Address - Country:US
Practice Address - Phone:401-461-6676
Practice Address - Fax:401-461-3165
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW018031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI413750OtherBLUE CHIP
1021740OtherNHP GROUP NUMBER
RIJR62069Medicaid
RI319458OtherBCBS
RI809005377Medicare PIN
RI007059240Medicare PIN