Provider Demographics
NPI:1811535834
Name:RIDDLE, JEREMY (RH)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:RH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1002
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-3002
Mailing Address - Country:US
Mailing Address - Phone:971-404-6452
Mailing Address - Fax:
Practice Address - Street 1:455 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2452
Practice Address - Country:US
Practice Address - Phone:971-404-6452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty