Provider Demographics
NPI:1548633985
Name:ETHRIDGE, JAMIE R (CNP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:R
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27025 OAKWOOD CIR
Mailing Address - Street 2:APT 128
Mailing Address - City:OLMSTED FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44138-3619
Mailing Address - Country:US
Mailing Address - Phone:440-225-4711
Mailing Address - Fax:
Practice Address - Street 1:20800 CENTER RIDGE RD
Practice Address - Street 2:STE 101
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-4312
Practice Address - Country:US
Practice Address - Phone:440-331-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17610-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163000Medicaid
OH0163000Medicaid