Provider Demographics
NPI:1053449504
Name:RICHARDSON, JIAJOYCE RENEE (CRNP)
Entity type:Individual
Prefix:MS
First Name:JIAJOYCE
Middle Name:RENEE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:JIAJOYCE
Other - Middle Name:RENEE
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:4518 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2921
Mailing Address - Country:US
Mailing Address - Phone:717-526-1030
Mailing Address - Fax:717-741-9605
Practice Address - Street 1:4518 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2921
Practice Address - Country:US
Practice Address - Phone:717-526-1030
Practice Address - Fax:717-741-9605
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009284363LF0000X
MDR149858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102130992-0001Medicaid
PA50078124OtherBLUE CROSS INDIVIDUAL
PA125050E7MOtherMEDICARE IND
MD893477-01OtherBLUE CROSS/BLUE SHIELD
MD4123778-00Medicaid
MDP633Medicare PIN
PA102130992-0001Medicaid