Provider Demographics
NPI:1356624654
Name:TIDD, JENNIFER A (MPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:TIDD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MICKLESON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-5564
Mailing Address - Country:US
Mailing Address - Phone:631-664-7844
Mailing Address - Fax:
Practice Address - Street 1:6000 GLENVIEW GARDEN PL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:984-465-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist