Provider Demographics
NPI:1891374419
Name:RIDER, JACKIE M
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:M
Last Name:RIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4963 US 30
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601
Mailing Address - Country:US
Mailing Address - Phone:724-610-7724
Mailing Address - Fax:
Practice Address - Street 1:4963 US 30
Practice Address - Street 2:SUITE 204
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:724-610-7724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001495101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional