Provider Demographics
NPI:1912335530
Name:JACKSON PEDIATRIC ASSOCIATES, LLC
Entity type:Organization
Organization Name:JACKSON PEDIATRIC ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-733-4627
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1029
Mailing Address - Country:US
Mailing Address - Phone:307-733-4627
Mailing Address - Fax:307-733-5184
Practice Address - Street 1:557 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-4627
Practice Address - Fax:307-733-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty