Provider Demographics
NPI:1184939027
Name:RYAN, JILL L (PHD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE SE STE 221
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4644
Mailing Address - Country:US
Mailing Address - Phone:505-345-9288
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE SE STE 221
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4644
Practice Address - Country:US
Practice Address - Phone:505-345-9288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1147103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist