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NPI Code Detail

MEDICARE: JENNIFER TISDALE

MEDICARE: JENNIFER TISDALE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social WorkerC017933NC
2104100000XSocial WorkerPO13258NC

General Provider Information

NPI Number : 1700443843
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER TISDALE
Provider Business Mailing Address
First Line : 1107 MORDECAI DR APT 202
Second Line :
City : RALEIGH
State : NC
Zip : 27604-1357
Country : US
Telephone Number : 919-413-7900
Fax Number :
Provider Business Practice Location Address
First Line : 136 US 70 HWY E
Second Line :
City : GARNER
State : NC
Zip : 27529-3982
Country : US
Telephone Number : 919-791-5611
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2019
Last Update Date : 12/26/2024

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