Healthcare Provider Details

I. General information

NPI: 1285187435
Provider Name (Legal Business Name): JENNA TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2016
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 BROADWAY
OAKLAND CA
94611-5714
US

IV. Provider business mailing address

3505 BROADWAY
OAKLAND CA
94611-5714
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-6298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC000665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: