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General NPI Number Information
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NPI Number | 1922252246
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Entity Type | Individual
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Provider Name | JACK RYAN LADC, LPC
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Gender | Male
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Dates
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Enumeration Date | 11/13/2008
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Last Update Date | 02/08/2019
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Provider Practice Location Address
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Address Line | 2475 ALBANY AVE STE 203B
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City | WEST HARTFORD
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State | CT
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Zip | 06117-2523
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Country | US
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Telephone | 860-519-6492
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Fax | 860-519-6492
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Provider Business Mailing Address
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Address Line | 53 MANOR LN
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-3214
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Country | US
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Telephone | 860-519-6492
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0008885
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 003589
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License Number State | CT
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