Provider Demographics
NPI:1356780647
Name:RIDLEN, JENNA L W (DO)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:L W
Last Name:RIDLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:LEE WILCOX
Other - Last Name:RIDLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-0833
Mailing Address - Fax:515-643-0933
Practice Address - Street 1:1350 DES MOINES STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5507
Practice Address - Country:US
Practice Address - Phone:515-643-0833
Practice Address - Fax:515-643-0933
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-04667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine