Provider Demographics
NPI:1114159688
Name:TIDWELL, JENNIE BREANNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:BREANNE
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:18 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-3603
Mailing Address - Country:US
Mailing Address - Phone:501-920-6808
Mailing Address - Fax:870-552-7115
Practice Address - Street 1:821 E PARK ST
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:AR
Practice Address - Zip Code:72024-9024
Practice Address - Country:US
Practice Address - Phone:870-552-7110
Practice Address - Fax:870-552-7115
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2314225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist