| Jonathan Ridenour, Pa | |
|
4801 Troup Hwy Ste 502 Tyler TX 75703-2357 | |
| (972) 424-9212 | |
| (972) 509-1450 |
| Full Name | Jonathan Ridenour, Pa |
|---|---|
| Speciality | Psychologist |
| Location | 4801 Troup Hwy Ste 502, Tyler, Texas |
| Authorized Official Name and Position | Michelle Bice (OFFICE MANAGER) |
| Authorized Official Contact | 9036305788 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Jonathan Ridenour, Pa 4801 Troup Hwy Ste 502 Tyler TX 75703-2357 Ph: (903) 630-5788 | Jonathan Ridenour, Pa 4801 Troup Hwy Ste 502 Tyler TX 75703-2357 Ph: (972) 424-9212 |
| NPI Number | 1699233403 |
|---|---|
| Provider Enumeration Date | 03/11/2019 |
| Last Update Date | 09/18/2023 |
| Certification Date | 09/18/2023 |
| Medicare PECOS PAC ID | 7517291685 |
|---|---|
| Medicare Enrollment ID | O20190624000850 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699233403 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | (* (Not Available)) | Primary |
| Provider Name | Jonathan M Ridenour |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1760703003 PECOS PAC ID: 9234302985 Enrollment ID: I20111025000866 |
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