Provider Demographics
NPI:1477978690
Name:TIDWELL, JAMALL (MHPP)
Entity Type:Individual
Prefix:
First Name:JAMALL
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ROSS AVENUE
Mailing Address - Street 2:
Mailing Address - City:ANTOINE
Mailing Address - State:AR
Mailing Address - Zip Code:71922
Mailing Address - Country:US
Mailing Address - Phone:870-379-2374
Mailing Address - Fax:
Practice Address - Street 1:829 HALBERT ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2607
Practice Address - Country:US
Practice Address - Phone:501-332-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator