Provider Demographics
NPI:1679684252
Name:RIDDELL, JENNIFER JO (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JO
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:JACK
Other - Last Name:LANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8303 DODGE ST
Mailing Address - Street 2:#225
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114
Mailing Address - Country:US
Mailing Address - Phone:402-354-5860
Mailing Address - Fax:402-354-2350
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:#225
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-354-5860
Practice Address - Fax:402-354-2350
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant