Provider Demographics
NPI:1952593568
Name:TIDSWELL, JESSICA J (PT, DPT, SCS, ATC)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:J
Last Name:TIDSWELL
Suffix:
Gender:F
Credentials:PT, DPT, SCS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5134
Mailing Address - Country:US
Mailing Address - Phone:801-718-5378
Mailing Address - Fax:
Practice Address - Street 1:2760 RASMUSSEN RD
Practice Address - Street 2:SUITE D2-D3
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5684
Practice Address - Country:US
Practice Address - Phone:801-718-5378
Practice Address - Fax:801-718-5378
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5080663-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist