Healthcare Provider Details

I. General information

NPI: 1700443843
Provider Name (Legal Business Name): JENNIFER TISDALE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 US 70 HWY E
GARNER NC
27529-3982
US

IV. Provider business mailing address

1107 MORDECAI DR APT 202
RALEIGH NC
27604-1357
US

V. Phone/Fax

Practice location:
  • Phone: 919-791-5611
  • Fax:
Mailing address:
  • Phone: 919-413-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC017933
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberPO13258
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: