Basic Information
| Provider Information | |||||||||
| NPI: | 1013390830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDGWAY | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEVRIES | ||||||||
| OtherFirstName: | JESSE | ||||||||
| OtherMiddleName: | RACHAL | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 590 COURT ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033546534 | ||||||||
| FaxNumber: | 4137941629 | ||||||||
| Practice Location | |||||||||
| Address1: | 590 COURT ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033546534 | ||||||||
| FaxNumber: | 4137941629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 03/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | VT | N | Other Service Providers | Specialist | 367A00000X | RN2321296 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 069271-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0004372 | 05 | VT | MEDICAID |