Provider Demographics
NPI:1720334741
Name:RYAN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MICKEY GILLEY AVE
Mailing Address - Street 2:
Mailing Address - City:FERRIDAY
Mailing Address - State:LA
Mailing Address - Zip Code:71334-2619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 MICKEY GILLEY AVE
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-2619
Practice Address - Country:US
Practice Address - Phone:318-757-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered