Basic Information
| Provider Information | |||||||||
| NPI: | 1285383828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | MICHELL | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421412604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708610606 | ||||||||
| FaxNumber: | 2706292444 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421412604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708610606 | ||||||||
| FaxNumber: | 2706292444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2022 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 3018432 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.