Provider Demographics
NPI:1013390830
Name:RIDGWAY, JESSE R (CNM)
Entity Type:Individual
Prefix:MRS
First Name:JESSE
Middle Name:R
Last Name:RIDGWAY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:JESSE
Other - Middle Name:RACHAL
Other - Last Name:DEVRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:590 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1719
Mailing Address - Country:US
Mailing Address - Phone:603-354-6534
Mailing Address - Fax:413-794-1629
Practice Address - Street 1:590 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1719
Practice Address - Country:US
Practice Address - Phone:603-354-6534
Practice Address - Fax:413-794-1629
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2020-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT174400000X
MARN2321296367A00000X
NH069271-23367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004372Medicaid
VTVT4372Medicare UPIN