Healthcare Provider Details

I. General information

NPI: 1679256028
Provider Name (Legal Business Name): RYAN JAKE BASS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE BASS PSYD

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 US ROUTE 60 STE A110
HUNTINGTON WV
25705-8859
US

IV. Provider business mailing address

3075 US ROUTE 60
HUNTINGTON WV
25705-8859
US

V. Phone/Fax

Practice location:
  • Phone: 304-528-4600
  • Fax:
Mailing address:
  • Phone: 304-528-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1338
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: