Provider Demographics
NPI:1558970939
Name:TIDWELL, JENNIFER BAREFOOT (NP-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:BAREFOOT
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BAREFOOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:140 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1522
Practice Address - Country:US
Practice Address - Phone:336-716-4131
Practice Address - Fax:336-713-0328
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF07202295363LF0000X
NC5013567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily