Provider Demographics
NPI:1831606664
Name:TIDWELL, JANA KAY (LMT)
Entity type:Individual
Prefix:MS
First Name:JANA
Middle Name:KAY
Last Name:TIDWELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3533
Mailing Address - Country:US
Mailing Address - Phone:318-487-0960
Mailing Address - Fax:318-487-2002
Practice Address - Street 1:3834 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3533
Practice Address - Country:US
Practice Address - Phone:318-487-0960
Practice Address - Fax:318-487-2002
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA2759225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist