Healthcare Provider Details

I. General information

NPI: 1831433317
Provider Name (Legal Business Name): JASMYNE TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 MANZANITA PARK ROAD
BEAUMONT CA
92223
US

IV. Provider business mailing address

14700 MANZANITA PARK ROAD
BEAUMONT CA
92223
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-3155
  • Fax: 951-845-8412
Mailing address:
  • Phone: 951-845-3155
  • Fax: 951-845-8412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: