Provider Demographics
NPI:1245667385
Name:RYAN, JERRY DAVID (LPCCRCNCC,MS)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DAVID
Last Name:RYAN
Suffix:
Gender:M
Credentials:LPCCRCNCC,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 548
Mailing Address - Street 2:19142 MOLALLA AVE, SUITE A
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-7166
Mailing Address - Country:US
Mailing Address - Phone:503-348-6177
Mailing Address - Fax:503-632-5497
Practice Address - Street 1:19142 MOLALLA AVE., SUITE A,
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-7166
Practice Address - Country:US
Practice Address - Phone:503-348-6177
Practice Address - Fax:593-632-5497
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR2757101YP2500X
OR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006884107Medicaid