Provider Demographics
NPI:1417622069
Name:JENNINGS-TIDWELL, RYAN CHRISTIAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:CHRISTIAN
Last Name:JENNINGS-TIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23633 SE GOLD RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97022-9790
Mailing Address - Country:US
Mailing Address - Phone:503-719-1518
Mailing Address - Fax:
Practice Address - Street 1:1042 SE 30TH PL
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-9456
Practice Address - Country:US
Practice Address - Phone:503-618-9668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR854291253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR854291OtherHCW PROVIDER NUMBER