Provider Demographics
NPI:1386362440
Name:RYAN, JESSICA NICOLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:DEATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5736 MANCHESTER HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37357
Mailing Address - Country:US
Mailing Address - Phone:931-815-3871
Mailing Address - Fax:
Practice Address - Street 1:5736 MANCHESTER HWY
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:TN
Practice Address - Zip Code:37357-7503
Practice Address - Country:US
Practice Address - Phone:931-815-3871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000093248164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse