Provider Demographics
NPI:1104504794
Name:RYDER, JACOB ISRAEL (LPC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ISRAEL
Last Name:RYDER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1765
Mailing Address - Country:US
Mailing Address - Phone:757-788-0300
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1763
Practice Address - Country:US
Practice Address - Phone:757-788-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012308101YP2500X
VA0710103463101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0710103463OtherCSAC
VA0701012308OtherLICENSE