Provider Demographics
NPI:1942722327
Name:RUDDY, JAMEE
Entity Type:Individual
Prefix:
First Name:JAMEE
Middle Name:
Last Name:RUDDY
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 1:38 N SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1888
Mailing Address - Country:US
Mailing Address - Phone:570-280-2800
Mailing Address - Fax:570-281-6245
Practice Address - Street 1:77 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:SIMPSON
Practice Address - State:PA
Practice Address - Zip Code:18407
Practice Address - Country:US
Practice Address - Phone:570-687-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1031020430001252Y00000X
253Z00000X, 332B00000X, 332BC3200X, 332BD1200X, 332BN1400X, 332BP3500X, 332BX2000X
PABH001866103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031020430001Medicaid
PA1031020430001OtherMEDICAL ASSISTANCE