Provider Demographics
NPI:1134648355
Name:RIDDER, JORDAN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:A
Last Name:RIDDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:A
Other - Last Name:OSBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4711 CENTERLINE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-1405
Mailing Address - Country:US
Mailing Address - Phone:865-647-3260
Mailing Address - Fax:865-647-3279
Practice Address - Street 1:4711 CENTERLINE DR STE 100
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-1405
Practice Address - Country:US
Practice Address - Phone:865-647-3260
Practice Address - Fax:865-647-3279
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032251Medicaid