1558970939 NPI number — MS. JENNIFER BAREFOOT TIDWELL NP-C

Table of content: MS. JENNIFER BAREFOOT TIDWELL NP-C (NPI 1558970939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558970939 NPI number — MS. JENNIFER BAREFOOT TIDWELL NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIDWELL
Provider First Name:
JENNIFER
Provider Middle Name:
BAREFOOT
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAREFOOT
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558970939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KIMEL FOREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-0238
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 CHARLOIS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-1522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-716-4131
Provider Business Practice Location Address Fax Number:
336-713-0328
Provider Enumeration Date:
07/30/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F07202295 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 5013567 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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