Provider Demographics
NPI:1770349144
Name:HENSON, JOHN RYAN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
Last Name:HENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 DEMAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-6071
Mailing Address - Country:US
Mailing Address - Phone:304-435-1884
Mailing Address - Fax:
Practice Address - Street 1:65 PROFESSIONAL PL STE 102
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0259
Practice Address - Country:US
Practice Address - Phone:304-848-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator