Provider Demographics
NPI:1588090476
Name:RYCKEGHEM, JASON ROBERT
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:RYCKEGHEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 53RD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7564
Mailing Address - Country:US
Mailing Address - Phone:563-322-0971
Mailing Address - Fax:563-324-0615
Practice Address - Street 1:2300 53RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7564
Practice Address - Country:US
Practice Address - Phone:563-322-0971
Practice Address - Fax:563-324-0615
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004669363A00000X
IA074029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant