Provider Demographics
NPI:1346330206
Name:RYDER, JAMIE A (PHD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:RYDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 641130
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-7130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 HARMONY ST
Practice Address - Street 2:SUITE 302
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-328-2609
Practice Address - Fax:712-328-2609
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001082103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200346670AMedicaid
Q53251Medicare UPIN
119870Medicare ID - Type Unspecified