Healthcare Provider Details

I. General information

NPI: 1629454855
Provider Name (Legal Business Name): JORDAN MARIE RYAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7477 E 46TH PL
TULSA OK
74145-6305
US

IV. Provider business mailing address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

V. Phone/Fax

Practice location:
  • Phone: 918-384-0002
  • Fax:
Mailing address:
  • Phone: 918-340-5503
  • Fax: 918-340-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7163
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: