Provider Demographics
NPI:1760703003
Name:RIDENOUR, JONATHAN MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 TROUP HWY STE 502
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2357
Mailing Address - Country:US
Mailing Address - Phone:903-630-5788
Mailing Address - Fax:903-630-5885
Practice Address - Street 1:4801 TROUP HWY STE 502
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2357
Practice Address - Country:US
Practice Address - Phone:903-630-5788
Practice Address - Fax:903-630-5885
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34806103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
34806OtherTEXAS LICENSE