Healthcare Provider Details

I. General information

NPI: 1245290162
Provider Name (Legal Business Name): JENNIFER L RYAN M.A., A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 EXCHANGE ST W SUITE 307
SAINT PAUL MN
55102-1045
US

IV. Provider business mailing address

502 RIVER ST
HASTINGS MN
55033-1734
US

V. Phone/Fax

Practice location:
  • Phone: 651-842-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1844
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: