Healthcare Provider Details

I. General information

NPI: 1225527351
Provider Name (Legal Business Name): TIDEWATER MOBILE MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 HIGH ST STE 100
PORTSMOUTH VA
23707-3126
US

IV. Provider business mailing address

3520 HIGH ST STE 100
PORTSMOUTH VA
23707-3126
US

V. Phone/Fax

Practice location:
  • Phone: 757-977-9675
  • Fax: 757-483-8099
Mailing address:
  • Phone: 757-977-9675
  • Fax: 757-483-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number46193
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JIMMY COOPER JR.
Title or Position: CEO/OWNER
Credential: DHA, FNP-C
Phone: 757-977-9675