Provider Demographics
NPI:1639182835
Name:RIDER, JANE ELLEN (MSW)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:ELLEN
Last Name:RIDER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 INGERSOLL
Mailing Address - Street 2:STE 205
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312
Mailing Address - Country:US
Mailing Address - Phone:515-279-2834
Mailing Address - Fax:515-279-4168
Practice Address - Street 1:3209 INGERSOLL
Practice Address - Street 2:STE 205
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312
Practice Address - Country:US
Practice Address - Phone:515-279-2834
Practice Address - Fax:515-279-4168
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14260Medicare ID - Type Unspecified