Healthcare Provider Details

I. General information

NPI: 1225541469
Provider Name (Legal Business Name): JESSICA MARIE RYDER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE RYDER

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR STE 300
DECATUR IL
62526-6322
US

IV. Provider business mailing address

4405 SAND CREEK RD
DECATUR IL
62521-8908
US

V. Phone/Fax

Practice location:
  • Phone: 217-428-6300
  • Fax: 217-428-6322
Mailing address:
  • Phone: 217-972-7677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016881
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: