Provider Demographics
NPI:1447806021
Name:RYAN, JENNIFER DESTREZA (MSN, AGNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DESTREZA
Last Name:RYAN
Suffix:
Gender:F
Credentials:MSN, AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 W 184TH PL
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-4813
Mailing Address - Country:US
Mailing Address - Phone:310-634-9739
Mailing Address - Fax:
Practice Address - Street 1:5315 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4011
Practice Address - Country:US
Practice Address - Phone:800-535-8446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012280363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology