Provider Demographics
NPI:1912012816
Name:RIDENOURE, JENNIFER (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RIDENOURE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2936 CAMBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3748
Mailing Address - Country:US
Mailing Address - Phone:954-704-0108
Mailing Address - Fax:
Practice Address - Street 1:1330 RIVERLAND RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-2961
Practice Address - Country:US
Practice Address - Phone:954-321-9826
Practice Address - Fax:954-321-9660
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103460363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292299100Medicaid
FLU6362ZMedicare ID - Type Unspecified