Provider Demographics
NPI:1629454160
Name:TIDWELL, JESSICA KING (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KING
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1501 KINGS HIGHWAY
Mailing Address - Street 2:ATTN: LEISA OGLESBY (MED SCH RM 1-201)
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-4881
Mailing Address - Fax:318-675-5069
Practice Address - Street 1:703 S FLEISHEL AVE
Practice Address - Street 2:STE 5000
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAAP08445363LA2100X
TXAP130723363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-123OtherTRICARE
TX752616977180OtherTRICARE
TX352279902Medicaid
TXP01784015OtherRAIL ROAD MEDICARE
TXP01784015OtherRAIL ROAD MEDICARE