Provider Demographics
NPI:1013556356
Name:TIDWELL, JESSI BLACKSTOCK (CRNP)
Entity Type:Individual
Prefix:
First Name:JESSI
Middle Name:BLACKSTOCK
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10005
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35631-2005
Mailing Address - Country:US
Mailing Address - Phone:256-394-0880
Mailing Address - Fax:
Practice Address - Street 1:106 MICHIGAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2730
Practice Address - Country:US
Practice Address - Phone:256-394-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-162142163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse