# JACKSON PEDIATRIC ASSOCIATES, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Jackson Pediatrics
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912335530
- **Authorized official:** DR. TRAVIS JOHN RIDDELL M.D. (PEDIATRICIAN)
- **Authorized official phone:** (307) 733-4627

## Contact information

- **Practice address:** 557 E BROADWAY AVE, JACKSON, WY 83001-8640
- **Practice address phone:** (307) 733-4627
- **Practice address fax:** (307) 733-5184
- **Mailing address:** PO BOX 1029, JACKSON, WY 83001-1029
- **Mailing address phone:** (307) 733-4627
- **Mailing address fax:** (307) 733-5184

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208000000X | Pediatrics Physician | — | NULL | Yes |
| 208000000X | Pediatrics Physician | — | — | Yes |
| 261QP2300X | Primary Care Clinic/Center | — | NULL | — |

## Other

- **Enumeration date:** 10/16/2013
- **Last updated:** 10/16/2013