Provider Demographics
NPI:1649655531
Name:TIDWELL, JESSICA
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681508
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1508
Mailing Address - Country:US
Mailing Address - Phone:615-661-7888
Mailing Address - Fax:615-661-9001
Practice Address - Street 1:209 S ROYAL OAKS BLVD
Practice Address - Street 2:#222
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-1310
Practice Address - Country:US
Practice Address - Phone:615-794-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000019981363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily