Healthcare Provider Details

I. General information

NPI: 1841579752
Provider Name (Legal Business Name): JORDAN LEIGH RYAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S 76TH ST # 305
MILWAUKEE WI
53220-4364
US

IV. Provider business mailing address

4811 S 76TH ST # 305
MILWAUKEE WI
53220-4364
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7741
  • Fax:
Mailing address:
  • Phone: 414-325-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number129512-121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9061-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: