Provider Demographics
NPI:1770167850
Name:RITENOUR, JASON (NP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RITENOUR
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7709 MAMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224
Mailing Address - Country:US
Mailing Address - Phone:919-830-6599
Mailing Address - Fax:
Practice Address - Street 1:8026 S TAMIAMI TRL STE 103
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5113
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011474A363LF0000X
FLAPRN11012847363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300053890Medicaid