Provider Demographics
NPI:1508291717
Name:RIDDER, JACOB JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JAMES
Last Name:RIDDER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 PIERCE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-1106
Mailing Address - Country:US
Mailing Address - Phone:402-933-3770
Mailing Address - Fax:402-933-3633
Practice Address - Street 1:12910 PIERCE ST STE 120
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-1106
Practice Address - Country:US
Practice Address - Phone:402-933-3770
Practice Address - Fax:402-933-3633
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1768207N00000X, 363AM0700X
IA002439363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1841673738Medicaid
NE10026411700Medicaid