Provider Demographics
NPI:1225527351
Name:TIDEWATER MOBILE MEDICINE, PLLC
Entity Type:Organization
Organization Name:TIDEWATER MOBILE MEDICINE, PLLC
Other - Org Name:AUTHENTIC SELF COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DHA, FNP-C
Authorized Official - Phone:757-977-9675
Mailing Address - Street 1:3520 HIGH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3126
Mailing Address - Country:US
Mailing Address - Phone:757-977-9675
Mailing Address - Fax:757-483-4099
Practice Address - Street 1:3520 HIGH ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3126
Practice Address - Country:US
Practice Address - Phone:757-977-9675
Practice Address - Fax:757-483-8099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDEWATER MOBILE MEDICINE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 1041C0700X, 207Q00000X, 343900000X
VA46193261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty