Provider Demographics
NPI:1093316457
Name:TIDWELL, JACALYN R
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:R
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACALYN
Other - Middle Name:R
Other - Last Name:KETCHERSIDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5310 E 31ST ST STE 600
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5018
Mailing Address - Country:US
Mailing Address - Phone:918-587-9471
Mailing Address - Fax:
Practice Address - Street 1:5310 E 31ST ST STE 600
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5018
Practice Address - Country:US
Practice Address - Phone:918-587-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist