Healthcare Provider Details

I. General information

NPI: 1912335530
Provider Name (Legal Business Name): JACKSON PEDIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 E BROADWAY AVE
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 1029
JACKSON WY
83001-1029
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4627
  • Fax: 307-733-5184
Mailing address:
  • Phone: 307-733-4627
  • Fax: 307-733-5184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAVIS JOHN RIDDELL
Title or Position: PEDIATRICIAN
Credential: M.D.
Phone: 307-733-4627