Healthcare Provider Details

I. General information

NPI: 1912875543
Provider Name (Legal Business Name): JAMIE JIVIDEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 IRISH HOLW
SMETHPORT PA
16749-4115
US

IV. Provider business mailing address

619 IRISH HOLW
SMETHPORT PA
16749-4115
US

V. Phone/Fax

Practice location:
  • Phone: 814-596-3172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH068273
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: